CJA
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Résumé de cet Article
Right arrow Full Text (PDF)
Right arrow Submit a scholarly reply
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Castagnini, H. E.
Right arrow Articles by Nathanson, M. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Castagnini, H. E.
Right arrow Articles by Nathanson, M. H.
Canadian Journal of Anesthesia 51:486-491 (2004)
© Canadian Anesthesiologists' Society, 2004
Neuroanesthesia and Intensive Care

Sevoflurane for interventional neuroradiology procedures is associated with more rapid early recovery than propofol

[Le sévoflurane, comparé au propofol, est associé à une récupération plus rapide en neuroradiologie interventionnelle]

Hugo E. Castagnini, MD*, Frank van Eijs, MD{dagger}, Frederick C. Salevsky, MD{ddagger} and Michael H. Nathanson, FRCA§

* From the Neuroradiology Research Institute FLENI, Buenos Aires, Argentina;
{dagger} The Saint Elisabeth Hospital, Tilburg, Netherlands;
{ddagger} The Montreal Neurological Hospital, Montreal, Quebec, Canada; and
§ The Queen’s Medical Centre, Nottingham, UK.

Address correspondence to: Dr. Michael Nathanson, Department of Anaesthesia, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK. Phone: 44 115 970 9195; Fax: 44 115 978 3891; E-mail: mike.nathanson{at}nottingham.ac.uk


   Abstract
TOP
 Abstract
Introduction
 Methods
 Results
 Discussion
 APPENDIX
 References
 
Purpose: Sevoflurane and propofol are both suitable for neuroanesthesia but have not previously been compared as maintenance agents for long duration (one to five hours) procedures.

Methods: Using a multicentre international study protocol, 103 patients were randomized to receive either sevoflurane or propofol for maintenance of anesthesia during interventional neuroradiology procedures. After a standardized induction of anesthesia with propofol, 53 patients received sevoflurane 1 to 3% with 60% nitrous oxide (N2O) in oxygen (O2), and 50 patients received propofol 4 to 10 mg•kg–1•hr–1 with 60% N2O in O2. Maintenance agents were titrated against systemic arterial blood pressure (baseline mean arterial pressure ± 20%). Recovery times, changes in sedation, pain, nausea and vomiting and psychomotor function during recovery and use of rescue medication were recorded.

Results: The group receiving sevoflurane had a more rapid recovery to spontaneous ventilation, extubation, eye opening and orientation compared to the group receiving propofol (3 vs 4 min, P = 0.01; 5 vs 6 min, P = 0.015; 7 vs 10 min, P < 0.001; 13 vs 17 min, P = 0.028; respectively). Sedation, pain, nausea and vomiting, and psychomotor function scores were similar in the two groups. Use of opioid boluses and vasopressors were similar.

Conclusion: The use of sevoflurane for maintenance of anesthesia for prolonged neuroradiological procedures is associated with more rapid early recovery than propofol and is associated with similar side effects. Sevoflurane and propofol can both be recommended for these procedures. The clinical benefit of the more rapid recovery with sevoflurane is unknown.


   Introduction
TOP
 Abstract
 Introduction
Methods
 Results
 Discussion
 APPENDIX
 References
 
ONE requirement of good neuroanesthetic practice both for traditional (open) surgical procedures and for interventional neurological procedures is the use of techniques and drugs that permit rapid recovery of consciousness and allow early assessment of the neurological status of the patient. It is also essential for the anesthetic agents used not to significantly alter the major parameters of cerebral circulation, such as carbon dioxide reactivity, intracranial pressure, cerebral blood flow and autoregulation. Sevoflurane has been shown to have a pharmacological profile suitable for neuroanesthesia,1 and has been associated with a short recovery profile, which supports its use for neuroanesthesia.2 Propofol is also associated with a rapid recovery and is suitable for use as a neuroanesthetic agent.3

This study is the first to compare recovery from sevoflurane and propofol for maintenance anesthesia during neurological procedures of one to five hours duration, for which the speed and quality of recovery are critical. Previous studies comparing these agents have predominantly examined their use during short procedures, particularly in ambulatory surgery. Few clinical studies have compared different anesthetic techniques for neuroanesthesia.4,5

We conducted a phase IV, single-blind, randomized, multicentre study to compare sevoflurane and propofol when used for maintenance of anesthesia for prolonged interventional neuroradiological procedures. The primary objective of the study was to determine if there is a difference in the early recovery profiles after the use of these agents. We also assessed their acceptability for these procedures.


   Methods
TOP
 Abstract
 Introduction
 Methods
Results
 Discussion
 APPENDIX
 References
 
Four centres in four countries (Argentina, the United Kingdom, the Netherlands and Canada) participated in the study. Institutional Review Board approval was obtained for each site. After obtaining informed consent, 108 patients were recruited into the study.

Inclusion criteria were: adult patients (aged 18–75 yr), able to give informed consent, ASA physical status I to III, and scheduled to undergo an interventional neuroradiology procedure (including embolization of an intracranial tumour, embolization of an arterio-venous malformation, embolization of an intracranial aneurysm) with an expected duration between one and five hours. Exclusion criteria included: pre-procedure Glasgow coma scale (GCS) less than 13, concurrent use of sedative medication, preexisting renal or hepatic dysfunction, and risk of pulmonary aspiration.

Patients were randomly assigned (by use of sealed envelopes) to one of two groups: group P = propofol for induction and propofol with 60% nitrous oxide (N2O) in oxygen (O2) for maintenance of anesthesia; group S = propofol for induction and sevoflurane with 60% N2O in O2 for maintenance of anesthesia. Of the 108 enrolled patients, 103 completed the study. Fifty of these patients were assigned to group P, and 53 patients were assigned to group S.

The following baseline variables were recorded prior to induction of anesthesia: heart rate (HR), mean arterial blood pressure (MAP; by a non-invasive method), peripheral blood oxygen saturation (SaO2), baseline scores for GCS, Ramsay sedation scale (Appendix), four-point scales for nausea and vomiting (none, mild, moderate, severe – as determined by patient), 10 cm visual analogue scales (VAS) for pain and sedation and digit-symbol substitution test (DSST).

Induction of anesthesia was performed similarly in both groups by iv administration of propofol 2–3 mg•kg–1, fentanyl 1 µg•kg–1 or alfentanil 10 µg•kg–1 and atracurium 0.5 mg•kg–1 or vecuronium 0.1 mg•kg–1. In both groups, either a laryngeal mask airway (LMA) or an endotracheal tube (ETT) was inserted (standardized for each centre). A circle system and ventilator were used to provide intermittent positive pressure ventilation. For the first five minutes of anesthesia, mechanical ventilation was performed with a fresh gas flow (FGF) rate of 6 L•min–1 made up of 60% N2O in O2, maintaining an end-tidal carbon dioxide concentration (EtCO2) of 30 to 37.5 mmHg. After five minutes, the FGF rate was reduced to 1 L•min–1 of 60% N2O in O2.

For maintenance of anesthesia, patients in group P received a continuous infusion of propofol, initially at a rate of 10 mg•kg–1•hr–1. After the first ten minutes, the infusion rate was titrated between 4 and 10 mg•kg–1•hr–1 to maintain MAP within 20% of the baseline (pre-induction) level. Patients in group S received sevoflurane at an inspired concentration of 1 to 3%, titrated to maintain MAP within 20% of baseline levels.

Additional doses of fentanyl or alfentanil were used to control increases in MAP not responding to a 50% increase in the inspired concentration of sevoflurane (group S) or to a bolus dose of 20 to 50 mg of propofol followed by a 50% increase in the propofol infusion rate (group P). Use of ephedrine to manage hypotension not responding to a reduction in anesthetic agent was recorded. During the maintenance period, atracurium or vecuronium was used to maintain one single twitch response to a train-of-four stimuli.

The following variables were recorded every two minutes for the first ten minutes of the procedure and every ten minutes thereafter: HR, MAP, SaO2, EtCO2. At the end of the procedure (as determined by the attending neuroradiologist), anesthesia was discontinued, residual neuromuscular blockade was reversed and the patient’s lungs were ventilated with 100% O2 at a FGF of 4 to 6 L•min–1.

The following recovery times were recorded: time to return of spontaneous ventilation, time to recovery from anesthesia (purposeful movement or eye opening on verbal command), time to extubation (removal of LMA or ETT), time to orientation (able to recall time, place and person), and time to be judged suitable for discharge from the recovery area. To be considered fit for discharge the patient had to be awake, maintaining their own airway, comfortable, cardiovascularly stable, and the femoral artery puncture site had to be dry. The patient’s neurological status had to be stable.

The following variables were recorded on admission to the recovery area and every 15 min thereafter for 60 min: GCS, Ramsay sedation scale, nausea and vomiting, VAS for pain and sedation, and DSST.

Continuous demographic variables were analyzed using an analysis of variance model. Recovery times were analyzed using the Wilcoxon rank-sum test. Hemodynamic and DSST data were analyzed using the general linear model for multiple comparisons. Categorical variables, including Ramsay scale score, GCS, and VAS for nausea and vomiting, were compared using Fisher’s exact test. All statistical tests were two-tailed, with a P value of < 0.05 considered statistically significant.


   Results
TOP
 Abstract
 Introduction
 Methods
 Results
Discussion
 APPENDIX
 References
 
Of the 108 patients enrolled in the study, eight patients experienced adverse events in group P and 12 in group S. Three of the adverse events in group P and six in group S were clearly related to the procedure and not to the study drug and in five of these patients the adverse event led to the withdrawal of the patient from the study (Table IGo). Data from these withdrawn patients were excluded from further analysis. No differences were found in the incidence of adverse events between the two groups.


View this table:
[in this window]
[in a new window]
  		TABLE I Withdrawn patients
 
The types of neuroradiological procedures performed in the study were embolization of cerebral artery aneurysm (51%), embolization of arteriovenous malformation (38%), embolization of intracranial tumour (6%) and others (5%). There were no differences between the groups in the distribution of these procedures. No differences were found in demographics, duration of anesthesia or duration of procedure between the two groups (Table IIGo).


View this table:
[in this window]
[in a new window]
  		TABLE II Demographic characteristics and duration of surgery and anesthesia
 
There were no differences between the groups in requirements for ephedrine (seven in each group), opioid boluses during maintenance (two in group S, one in group P) or antiemetic therapy postprocedure (three in group S, zero in group P, P = 0.24). No differences were seen in MAP or HR during maintenance between the two groups.

Times to spontaneous ventilation, extubation, recovery from anesthesia (eye opening) and orientation were shorter in the patients receiving sevoflurane (Table IIIGo). Times to be judged fit for transfer from the recovery room were similar between the groups. A post-hoc power analysis has shown that the power of this study to detect a difference (where {alpha} = 0.05) for time to spontaneous ventilation, time to extubation, time to eye opening and time to orientation is 79%, 98%, 98% and < 1% respectively.


View this table:
[in this window]
[in a new window]
  		TABLE III Recovery times (minutes)
 
The mean change from baseline in DSST scores is shown in Figure 1Go. Mean DSST scores were similar between the groups at all time points, with the exception of a small difference between the groups on admission to the recovery area. The two groups had similar VAS scores for sedation during the recovery period (Figure 2Go), as well as similar Ramsay sedation scale scores.



View larger version (11K):
[in this window]
[in a new window]
  		FIGURE 1 Change from baseline in digit-symbol substitution test during recovery from sevoflurane and propofol anesthesia.

 


View larger version (13K):
[in this window]
[in a new window]
  		FIGURE 2 Visual analogue scale scores for sedation during recovery from sevoflurane and propofol anesthesia.

 
There were no differences in the GCS, VAS scores for pain, nausea scores or vomiting scores between the groups.


   Discussion
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
APPENDIX
 References
 
The primary objective of this study was to compare the speed of recovery after prolonged anesthesia with sevoflurane or propofol. Our results demonstrate that in patients undergoing interventional neuroradiological procedures of one to five hours duration, the use of sevoflurane was associated with more rapid early recovery compared to propofol. The reductions in times to eye opening, return of spontaneous ventilation and extubation were between one and four minutes. Rapid recovery may be of benefit to neuroanesthesiologists and neuroradiologists who wish to see a rapid return to consciousness in order to permit early assessment of neurological function after these potentially high-risk procedures and, notwithstanding the differences in early recovery, this was achieved with both techniques. Early assessment of neurosurgical and neuroradiological patients is considered desirable although outcome data to support this belief are not available. To demonstrate that the more rapid early recovery we observed was of benefit would require a much larger study than this.

The difference in recovery measured in this study mirrors that seen in many of the studies that have looked predominantly at shorter duration (usually day-case) anesthesia.6 It is of interest that despite two to three hours duration of anesthesia, a difference was seen between sevoflurane and propofol. There is little published work on the comparison of these agents for prolonged procedures. Eger et al.7 found that increasing the duration of anesthesia up to eight hours is associated with longer recovery times for both desflurane and sevoflurane. Jellish et al.8 found that after elective surgical procedures lasting approximately two hours, sevoflurane anesthesia was associated with more rapid times to extubation, to obey commands and to orientation than propofol anesthesia (9 vs 13 min, 11 vs 14 min and 15 vs 20 min, respectively). Conversely, a study comparing single agent anesthesia with sevoflurane or propofol for spinal surgery lasting two to 2.5 hr found no difference in recovery times.9 However, all patients had received morphine intraoperatively, which may have masked any differences in recovery. When the results from a number of studies were pooled, it was found that increasing the duration of sevoflurane anesthesia (three to five hours) did not result in a reciprocal increase in recovery times.10 Todd et al. compared three techniques for maintenance of anesthesia for craniotomy surgery. They found very few differences in recovery from anesthesia in patients receiving either a propofol/fentanyl or an isoflurane/N2O-based technique. Time to orientation was shorter (10 vs 20 min) in those patients who had received propofol/fentanyl.4 Talke et al. found no difference in recovery between a propofol-based and an isoflurane-based technique.5

We measured a small difference in psychomotor function at one time point only. The similarity in sedation scores and psychomotor scores suggests that there is little difference between these agents during the early recovery period once the patient is awake. There were no differences in the other outcomes - pain, nausea and vomiting - and the hemodynamic variables. These procedures are not usually associated with postprocedure pain. Similarly, the absence of a difference in nausea and vomiting scores might be expected after procedures that are not commonly associated with postoperative nausea and vomiting (PONV). Although some researchers have reported an increase in PONV associated with sevoflurane use,11,12 others have found no difference.8,9 Use of an anesthesia technique without the concomitant use of long-acting opioids may have contributed to the overall low rate of PONV in this study.

It may be argued that recovery from sevoflurane anesthesia was more rapid because of a different depth of anesthesia during the procedure and, in particular, during the period leading up to the end of the procedure. We might have used a ‘depth-of-anesthesia’ monitor, such as the bispectral index, which might also have prevented excessively deep anesthesia and led to shorter recovery times.13 Instead, we decided to titrate the depth of anesthesia against hemodynamic variables, particularly MAP. This technique may not ensure a similar depth of anesthesia, as the two agents may modify the blood pressure response to stimuli by different mechanisms. These procedures are not stimulating, however, and in the absence of a major intracranial catastrophe, blood pressure is a useful indicator of anesthesia depth. Furthermore, titrating the administration of maintenance agents against the MAP best mimics usual clinical practice.

Use of sevoflurane for prolonged procedures may raise concern regarding the total amount of sevoflurane administered (MAC-hours). A limit of the use of this drug at low flow rates exists in the United States and some other countries; however, many countries do not have this limitation. This subject remains at the centre of much controversy at present.14 Although interventional neuroradiological procedures can be prolonged, the amount of maintenance agent administered is often limited and the total dose administered remains low. Our protocol allowed administration of sevoflurane up to 3% inspired. However, for the majority of patients in the sevoflurane group, the average inspired concentration during the maintenance period was much less than the 3% inspired concentration allowed (Nathanson MH, unpublished observation).

In conclusion, we found that use of sevoflurane for maintenance of anesthesia for neuroradiological procedures of one to five hours duration was associated with more rapid early recovery (one to four minutes) than propofol. No differences were found in sedation, pain, PONV or psychomotor function. Sevoflurane and propofol can both be recommended for these procedures. The more rapid early recovery with sevoflurane may be an advantage, but the clinical significance of this difference is unknown.


   APPENDIX
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
 APPENDIX
References
 
Ramsay sedation scale:

  1. - Anxious, agitated or restless;
  2. - Cooperative, orientated and tranquil;
  3. - Responds to commands;
  4. - Asleep, but with brisk response to light glabellar tap or auditory stimulus;
  5. - Asleep, sluggish response to light glabellar tap or auditory stimulus;
  6. - Asleep, no response.


   Footnotes
 
Support: This work was supported by Abbott Laboratories, Abbott Park, Illinois, USA. Presented in part at the Annual Meeting of the American Society of Anesthesiologists, Dallas, TX, USA.

Accepted for publication July 8, 2003. Revision accepted February 18, 2004.


   References
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
 APPENDIX
 References
 
1 Duffy CM, Matta BF. Sevoflurane and anesthesia for neurosurgery. A review. J Neurosurg Anesthesiol 2000; 12: 128–40.[Medline]

2 Umbrain V, Keeris J, D’Haese J, et al. Isoflurane, desflurane and sevoflurane for carotid endarterectomy. Anaesthesia 2000; 55: 1052–7.[Medline]

3 Smith I, White PF, Nathanson M, Gouldson R. Propofol. An update on its clinical use. Anesthesiology 1994; 81: 1005–43.[Medline]

4 Todd MM, Warner DS, Sokoll MD, et al. A prospective, comparative trial of three anesthetics for elective supratentorial craniotomy. Anesthesiology 1993; 78: 1005–20.[Medline]

5 Talke P, Caldwell JE, Brown R, Dodson B, Howley J, Richardson CA. A comparison of three anesthetic techniques in patients undergoing craniotomy for supratentorial intracranial surgery. Anesth Analg 2002; 95: 430–5.[Abstract/Free Full Text]

6 Robinson BJ, Uhrich TD, Ebert TJ. A review of recovery from sevoflurane anaesthesia: comparisons with isoflurane and propofol including meta-analysis. Acta Anaesthesiol Scand 1999; 43: 185–90.[Medline]

7 Eger EI II, Gong D, Koblin DD, et al. The effect of anesthetic duration on kinetic and recovery characteristics of desflurane versus sevoflurane, and on the kinetic characteristics of compound A, in volunteers. Anesth Analg 1998; 86: 414–21.[Abstract]

8 Jellish WS, Lien CA, Fontenot HJ, Hall R. The comparative effects of sevoflurane versus propofol in the induction and maintenance of anesthesia in adult patients. Anesth Analg 1996; 82: 479–85.[Abstract]

9 Watson KR, Shah MV. Clinical comparison of ‘single agent’ anaesthesia with sevoflurane versus target controlled infusion of propofol. Br J Anaesth 2000; 85: 541–6.[Abstract/Free Full Text]

10 Ebert TJ, Robinson BJ, Uhrich TD, Mackenthun A, Pichotta PJ. Recovery from sevoflurane anesthesia. A comparison to isoflurane and propofol anesthesia. Anesthesiology 1998; 89: 1524–31.[Medline]

11 Fredman B, Nathanson MH, Smith I, Wang J, Klein K, White PF. Sevoflurane for outpatient anesthesia: a comparison with propofol. Anesth Analg 1995; 81: 823–8.[Abstract]

12 Nathan N, Peyclit A, Lahrimi A, Feiss P. Comparison of sevoflurane and propofol for ambulatory anaesthesia in gynaecological surgery. Can J Anaesth 1998; 45: 1148–50.[Abstract/Free Full Text]

13 Song D, Joshi GP, White PF. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia. Anesthesiology 1997; 87: 842–8.[Medline]

14 Kharasch ED. Pharmacovigilance and safety aspects of sevoflurane. Acta Anaesthesiol Scand 1997; 41(Suppl 111): 146–8.[Medline]




This article has been cited by other articles:


Home page
 Contin Educ Anaesth Crit Care PainHome page
I.L. Dorairaj and S.M. Hancock
Anaesthesia for interventional neuroradiology
CEACCP, June 1, 2008; 8(3): 86 - 89.
[Full Text] [PDF]

Home page
 Br J AnaesthHome page
M. K. Varma, K. Price, V. Jayakrishnan, B. Manickam, and G. Kessell
Anaesthetic considerations for interventional neuroradiology
Br. J. Anaesth., July 1, 2007; 99(1): 75 - 85.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Résumé de cet Article
Right arrow Full Text (PDF)
Right arrow Submit a scholarly reply
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Castagnini, H. E.
Right arrow Articles by Nathanson, M. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Castagnini, H. E.
Right arrow Articles by Nathanson, M. H.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS