The usefulness of dual channel elastomeric pump for intravenous patient-controlled analgesia in geriatrics: a randomized, double-blind, prospective study.

BACKGROUND: Intravenous patient-controlled analgesia (IV-PCA) is often used in the postoperative period. However, determining an appropriate opioid dose is difficult. A previous study suggested the usefulness of variable-rate feedback infusion. In this study, we used a dual-channel elastomeric infusion pump to provide changes in PCA infusion rate by pain feedback. METHODS: Ninety patients undergoing orthopedic surgery of American Society of Anesthesiologists grade I-III and 65 to 79 years of age participated in the study. All patients were given a dual-chamber PCA. Patients were randomly allocated to a treatment group (Group D; PCA drugs divided into both chambers) or control group (Group C; PCA drugs only in the constant flow chamber with normal saline in the adjustable flow chamber). The primary outcome was the amount of fentanyl consumption via PCA bolus. The secondary outcome variables were pain score, total fentanyl consumption, rescue analgesic use, patient satisfaction, recovery scores, and adverse events including postoperative nausea and vomiting (PONV). RESULTS: Group D showed decreased fentanyl consumption of the PCA bolus, a decrease in rescue analgesic use, and better patient satisfaction compared with group C. The incidence of PONV was much higher in group C. There was no difference in other adverse events. CONCLUSIONS: We showed the usefulness of dual chamber IV-PCA to change the flow rate related to pain feedback without any complications. Our results suggest a noble system that might improve existing IV-PCA equipment. TRIAL REGISTRATION: The study registered at UMIN clinical trial registry (registered date: 05/03/2020, registration number: UMIN000039702 ).

Comparison between the trapezius and adductor pollicis muscles as an acceleromyography monitoring site for moderate neuromuscular blockade during lumbar surgery.

Acceleromyography at the adductor pollicis located in a distal part of the body may not reflect the degree of neuromuscular blockade (NMB) at the proximally located muscles manipulated during lumbar surgery. We investigated the usefulness and characteristics of acceleromyographic monitoring at the trapezius for providing moderate NMB during lumbar surgery. Fifty patients were randomized to maintain a train-of-four count 1-3 using acceleromyography at the adductor pollicis (group A; n = 25) or the trapezius (group T; n = 25). Total rocuronium dose administered intraoperatively [mean ± SD, 106.4 ± 31.3 vs. 74.1 ± 17.6 mg; P < 0.001] and surgical satisfaction (median [IQR], 7 [5-8] vs. 5 [4-5]; P < 0.001) were significantly higher in group T than group A. Lumbar retractor pressure (88.9 ± 12.0 vs. 98.0 ± 7.8 mmHg; P = 0.003) and lumbar muscle tone in group T were significantly lower than group A. Time to maximum block with an intubating dose was significantly shorter in group T than group A (44 [37-54] vs. 60 [55-65] sec; P < 0.001). Other outcomes were comparable. Acceleromyography at the trapezius muscle during lumbar surgery required a higher rocuronium dose for moderate NMB than the adductor pollicis muscle, thereby the consequent deeper NMB provided better surgical conditions. Trapezius as proximal muscle may better reflect surgical conditions of spine muscle.

Lung ultrasound score-based perioperative assessment of pressure-controlled ventilation-volume guaranteed or volume-controlled ventilation in geriatrics: a prospective randomized controlled trial.

PURPOSE: Recent studies have shown the potential benefits of pressure-controlled ventilation-volume guaranteed (PCV-VG) compared to volume-controlled ventilation (VCV), but the results were not impressive. We assessed the effects of PCV-VG versus VCV in elderly patients by using lung ultrasound score (LUS). PATIENTS AND METHODS: Elderly patients (aged 65-90 years) scheduled for hip joint surgery were randomly assigned to either the PCV-VG or VCV group during general anesthesia. LUS and mechanical ventilator parameters were evaluated before induction, 30 mins after a semi-lateral position change, during supine repositioning before awakening, and 15 mins after arrival to the post-anesthesia care unit (PACU). Pulmonary function tests were performed before and after surgery. Other recovery indicators were also assessed in the PACU. RESULTS: A total of 76 patients (40 for PCV-VG and 36 for VCV) were included this study. Demographic data showed no significant difference between the two groups. In both groups, LUSs before induction were significantly lower than those at other time points. LUSs of the VCV group were significantly increased during perioperative periods compared with the PCV-VG group (p=0.049). Visualized LUS modeling suggested an intuitive difference in the two groups and unequal distribution in lung aeration. Higher dynamic compliance and lower inspiratory peak pressure were observed in the PVC-VG group compared to the VCV group (33.54 vs 27.36, p<0.001; 18.93 vs 21.19, p<0.001, respectively). Postoperative forced vital capacity of the VCV group was lower than that of PCV-VG group, but this result was not significant (2.06 vs 1.79, respectively; p=0.091). The other respiratory data are comparable between the two groups. CONCLUSION: The PCV-VG group showed better LUS compared with the VCV group. Moreover, LUS modeling in both groups suggests non-homogeneous and positional change in lung aerations during surgery. CLINICAL TRIAL REGISTRATION: This study was registered at the UMIN clinical trials registry (unique trial number: UMIN000029355; registration number: R000033510).

The effect of nicardipine on the surgical pleth index during thyroidectomy under general anesthesia: A prospective double-blind randomized controlled trial.

BACKGROUND: The effectiveness of surgical pleth index (SPI) for managing nociception-antinociception balance during general anesthesia with vasodilators, including nicardipine has not been demonstrated. We aimed to compare the time course during surgery in SPI values in patients receiving nicardipine or remifentanil infusion during thyroidectomy. METHODS: Forty patients undergoing thyroidectomy were randomly assigned to receive nicardipine (group N; n = 19) or remifentanil (group R; n = 21) along with induction (propofol, fentanyl, and rocuronium) and maintenance (50% desflurane/nitrous oxide in oxygen) anesthesia (goal bispectral index [BIS] ∼50). The infusion of nicardipine or remifentanil was started before the 1st incision and adjusted to keep mean blood pressure (MBP) within ±20% of the preoperative value. SPI, BIS, end-tidal desflurane concentration (EtDes), MBP, and heart rate were recorded at 2.5 minute intervals from the 1st incision to the end of surgery. Extubation and recovery times, pain score/rescue ketorolac consumption, and adverse events in postanesthesia care unit (PACU) were recorded. RESULTS: The trend of SPI during surgery was comparable between the 2 groups (P = 0.804), although the heart rates in group N were significantly higher than those in group R (P = 0.040). The patient characteristics, trends of BIS, EtDes, and MBP during surgery, extubation and recovery times, and incidence of nausea/vomiting were comparable between the groups. Group N had significantly lower pain scores and rescue ketorolac consumption at PACU. CONCLUSION: SPI was comparable between patients receiving nicardipine or remifentanil infusion during thyroidectomy under general anesthesia, which suggests that the administration of nicardipine may confound the interpretation of SPI values during general anesthesia. CLINICAL TRIAL REGISTRATION: This trial was registered in the UMIN clinical trials registry (unique trial number: UMIN000019058; registration number: R000022028; principal investigator's name: Young Ju Won; date of registration: September 17, 2015).

The utility of bispectral index monitoring for prevention of rocuronium-induced withdrawal movement in children: A randomized controlled trial.

BACKGROUND: This study was designed to determine whether a deep hypnotic state with a bispectral index (BIS) value less than 40 could alleviate withdrawal movement (WM) upon rocuronium injection during anesthesia induction in children. METHODS: Finally, 135 healthy children (3-12 years) scheduled for minor elective surgery were studied. Without premedication, anesthesia was induced with thiopental sodium 5 mg/kg. Patients were randomized into 2 groups (control vs experimental) and then by virtue of rocuronium injection time, patients in the experimental group were allocated into 2 groups, as follows: in the control group (group C; n = 45), rocuronium 0.6 mg/kg was administered at the loss of eyelash reflex; in the 1st experimental group, rocuronium 0.6 mg/kg was administered when BIS fell to less than 40 (group T; n = 45); however, if BIS did not fall below 40 after thiopental sodium administration, manual ventilation was provided with oxygen 6 L/minute using sevoflurane 8% and then rocuronium was administered when BIS fell below 40 (the 2nd experimental group, group S; n = 45). Rocuronium-induced WM was evaluated using a 4-point scale (no movement; movement/withdrawal involving the arm only; generalized response, with movement/withdrawal of more than 1 extremity, but no requirement for restraint of the body; and generalized response which required restraint of the body and caused coughing or breath-holding). RESULTS: No significant differences were found among the groups for patient characteristics including age, sex, height, and location of venous cannula. However, body weight, height, and body mass index in group S were all smaller than those in group T. The incidence of WM caused by rocuronium was 100% in group C, 95.6% in group T, and 80% in group S, and was significantly lower in group S than in group C. The grade of WM was 3.7 ±â€Š0.6 in group C, 3.2 ±â€Š0.9 in group T, and 2.6 ±â€Š1.0 in group S. It was significantly lower in group T than in group C and significantly lower in group S than in groups C and T. CONCLUSION: The confirmation of a deep hypnotic state with BIS values lower than 40 using BIS monitoring can reduce the grade of rocuronium-induced WMs during anesthesia induction using thiopental sodium or sevoflurane in children.

Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: A systematic review and meta-analysis.

BACKGROUND: Previous studies have shown that sugammadex, a modified γ-cyclodextrin, is a well-tolerated agent for the reversal of neuromuscular blockade (NMB) induced by a steroidal neuromuscular blocking drug in adult patients. However, its use has not been reviewed in pediatric patients. The aim of this meta-analysis was to evaluate the efficacy and safety of sugammadex in the reversal of rocuronium-induced NMB during surgery under general anesthesia in pediatric patients. METHODS: A literature search was performed using the Pubmed, EMBASE: Drugs and pharmacology, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Analysis was conducted using RevMan 5.3. Data collected from different trials were pooled; the weighted mean difference or the pooled risk ratio and the corresponding 95% confidence interval (CI) were used for analysis, and heterogeneity (I) assessment was performed. RESULTS: Six randomized controlled trials comparing 253 pediatric patients (age range, 2-18 years) were included in the final analysis. The mean time taken to reach a train-of-four ratio of ≥0.9 was significantly shorter in the sugammadex groups (2 and 4 mg/kg) than in the control group (neostigmine or placebo), although the heterogeneity was high. The weighted mean differences of the 2 and 4 mg/kg sugammadex groups were -7.15 (95% CI: -10.77 to -3.54; I = 96%; P = 0.0001) and -17.32 (95% CI: -29.31 to -5.32; I = 98%; P = 0.005), respectively. The extubation time in the sugammadex group was shorter than that in the control group; the weighted mean difference of the sugammadex group was -6.00 (95% CI: -11.46 to -0.53; I = 99%; P = 0.03). There was no significant difference between the groups in terms of the incidence of postanesthetic adverse events; the pooled risk ratio was 0.67 (95% CI: 0.27-1.71; I = 59%; P = 0.41). CONCLUSION: We suggest that sugammadex is fast and effective in reversing rocuronium-induced NMB in pediatric patients. Although there was no evidence of a higher incidence of adverse events with sugammadex compared to that with neostigmine or placebo, much more data regarding the safety of sugammadex in pediatric patients may be still required.

Comparison of Surgical Pleth Index-guided Analgesia with Conventional Analgesia Practices in Children: A Randomized Controlled Trial.

BACKGROUND: To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children. METHODS: This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 µg/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements. RESULTS: Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 µg/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 µg/kg; P = 0.04). CONCLUSIONS: As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.

The analgesic effect of nefopam combined with low dose remifentanil in patients undergoing middle ear surgery under desflurane anesthesia: a randomized controlled trial.

BACKGROUND: We investigated the effects of the combined administration of nefopam, a N-methyl-D-aspartate receptor antagonist and low dose remifentanil, on early postoperative pain and analgesic requirement. METHODS: Fifty patients scheduled to undergo mastoidectomy and tympanoplasty were randomized to be given either nefopam 40 mg mixed with normal saline 100 ml (Group N) or an equal amount of normal saline (Group C) before anesthesia induction. Anesthesia was maintained with 5-6 vol% desflurane and remifentanil 0.05-0.15 µg/kg/min during the surgery. Postoperative pain was controlled by titration of ketorolac in the postanesthesia care unit (PACU) and ward. We evaluated the intraoperative remifentanil dose, recovery profiles, ketorolac demand in the PACU and ward, numeric rating scale (NRS) for pain at time intervals of every 10 min for 1 h in the PACU, 6, 12, 18 and 24 h in a ward, as well as the time to first analgesic requirement in the PACU and ward. RESULTS: Ketorolac demand and NRS in the PACU were significantly lower in Group N than Group C (P = 0.002, P = 0.005, respectively). The time to first analgesic requirement in the PACU in Group N were significantly longer than Group C (P = 0.046). There were no significant differences in intraoperative remifentanil dose, ketorolac demand, NRS, and the time to first analgesic requirement in the ward between the groups. CONCLUSIONS: Nefopam administration combined with low dose remifentanil infusion reduces pain and analgesic consumption during the immediate postoperative period in patients undergoing middle ear surgery under desflurane anesthesia.

Comparison of bispectral index scores from the standard frontal sensor position with those from an alternative mandibular position.

BACKGROUND: The standard bifrontal application of the bispectral index (BIS) sensor interferes with the operative field in neurosurgery and plastic surgery. The aim of this study was to compare the standard frontal BIS sensor position with an alternative position across the mandible. METHODS: Two BIS™ Quatro sensors (Aspect Medical Systems, Newton, MA, USA) mounted on the frontal and mandibular regions were connected to BIS Vista™ monitors on each patient during general anesthesia. Data from each position were collected at awake, loss of consciousness, intubation, incision, every 30 minutes during the intraoperative period and emergence. These data were compared using Bland-Altman and scatter plot analyses. RESULTS: Scatter plot analysis revealed a significant correlation between BIS values of frontal and mandibular positions (R = 0.869, P = 0.000), except during emergence (R = 0.253, P = 0.077). Bland-Altman analysis revealed a negative bias of 3.2 with a limit of agreement of 16.5/-22.9, in which 3.7% of the values were outside of the limit of agreement. Additional values included -2.9 (14.1/-8.3) while patients were awake, -21.7 (14.9/-58.3) at loss of consciousness, -1.8 (9.0/-12.5) during maintenance, and -1.9 (14.9/-18.8) during emergence. CONCLUSIONS: Overall, BIS values do not agree between the standard frontal position and an alternative mandibular position. However, during the anesthesia maintenance period, the mandibular position can be availably used as an alternative position if the operative field renders the standard frontal position unavailable.

Public awareness about the specialty of anesthesiology and the role of anesthesiologists: a national survey.

BACKGROUND: The aims of this national survey were to determine the views of Korean people regarding the specialty of anesthesiology and the role of anesthesiologists and to consider the ways in which individual anesthesiologists and the Korean Society of Anesthesiologists inform the public. METHODS: This off-line national survey was conducted by a professional research organization to obtain exact and reliable data. The questionnaire included structured questions to identify perceptions of the specialty of anesthesiology and the role of anesthesiologists inside and outside the operating room, people's desire for explanation of anesthesia by anesthesiologists, and their opinion about the best way to raise awareness about anesthesia and anesthesiologists. RESULTS: Of the respondents, 25.2% did not know that anesthesiologists are in charge of anesthesia during surgery. Furthermore, even respondents who knew that had very little knowledge of anesthesiologists' actual roles inside and outside the operating room. Respondents wanted their anesthesiologist to inform them about their anesthesia. CONCLUSIONS: The public's awareness regarding the role of anesthesiologists seems to be inadequate. To improve this awareness, in hospitals, each anesthesiologist should provide patients with more exact and detailed information. Simultaneously, the National Society of Anesthesiology should provide systematic information reflecting the public's thoughts.

Comparison of emergence agitation between sevoflurane/nitrous oxide administration and sevoflurane administration alone in children undergoing adenotonsillectomy with preemptive ketorolac.

BACKGROUND: Sevoflurane anesthesia commonly causes emergence agitation (EA) in children. One previous study has reported that the use of nitrous oxide (N2O) during the washout of sevoflurane may reduce EA by decreasing the residual sevoflurane concentration, while many animal studies suggest that N2O poses a potential risk to children. The present study was designed to compare EA in children assigned to receive sevoflurane with N2O (group N) or sevoflurane alone (group S). METHODS: We enrolled 80 children aged 3-10 years. Anesthesia was induced with 5 mg/kg thiopental sodium, 0.6 mg/kg rocuronium and 0.5 mg/kg ketorolac, and was maintained with 50% N2O and sevoflurane in group N or with sevoflurane alone in group S. The sevoflurane concentration was adjusted with a bispectral index (BIS) of 40-60. After completion of the surgery, N2O and sevoflurane were simultaneously discontinued and replaced with oxygen (O2) at 6 L/min. End-tidal sevoflurane concentration (Et Sevo) (%), BIS at the end of surgery, Et Sevo at recovery of self-respiration and emergence profiles were recorded. EA occurrence, pain score and rescue fentanyl consumption were assessed in the postanesthesia care unit. RESULTS: Et Sevo was significantly lower in group N (1.9%) than in group S (2.3%) at the end of surgery. However, there were no differences in Et Sevo at recovery of self-respiration, emergence times, the incidence of EA, pain score or dose of rescue fentanyl between the groups. CONCLUSIONS: In children undergoing adenotonsillectomy with preemptive ketorolac, anesthetic maintenance using sevoflurane alone does not affect the incidence of EA or emergence profiles compared to anesthetic maintenance using sevoflurane with N2O.

Slow injection of nefopam reduces pain intensity associated with intravenous injection: a prospective randomized trial.

PURPOSE: We aimed to investigate the frequency and severity of pain associated with intravenous injection of nefopam and to determine whether a slow rate of administration can effectively reduce such pain. METHODS: We used a solution containing 30 mg nefopam diluted to 20 ml in saline. In all, 102 adult patients undergoing minor surgery were randomly allocated to one of three administration groups: A (60 ml/h, n = 34); B (120 ml/h, n = 34); or C (180 ml/h, n = 34). All patients scored the maximal pain experienced during the 120-s infusion period, using the visual analogue scale (VAS) and the verbal pain score (VPS). Adverse events including phlebitis were recorded. RESULTS: Eighty-three patients (29 in group A, 27 each in groups B and C) were included in the final analysis. The incidence of injection pain was lower in group A (86.2 %) than in groups B (96.3 %) and C (100 %), but this difference was not statistically significant. The proportion of patients with a tolerable level of pain (VAS 0-3 and VPS 0-1) was significantly higher in group A (79.3 %) versus groups B (7.4 %) and C (3.7 %). The mean VAS scores for groups A, B, and C were 2.2 ± 1.3, 5.1 ± 1.6, and 7.2 ± 1.7, respectively, and these differences were statistically significant. CONCLUSIONS: At the slower rate of infusion (60 ml/h) of the 1.5 mg/ml nefopam solution, injection pain intensity was attenuated to a significantly greater degree than at the faster rates.

Antihistamine pretreatment to reduce incidence of withdrawal movement after rocuronium injection.

The purpose of this study was to determine the effectiveness of antihistamine therapy for withdrawal movements caused by rocuronium injection. One hundred seventy one ASA I-II adults undergoing elective surgery were randomly assigned to one of two groups. Patients in the control group (Group C) were premedicated with 2 mL normal saline, and those in the antihistamine group (Group A) were pre-medicated with 2 mL (45.5 mg) pheniramine maleate. After the administration of thiopental sodium 5 mg/kg, rocuronium 0.6 mg/kg was injected. Withdrawal movements were assessed using a four-grade scale. The administration of antihistamine reveals lower grade of withdrawal movement after rocuronium injection.

Thoracic spinal cord stimulation for neuropathic pain after spinal meningioma removal: a case report.

Spinal cord stimulation (SCS) is highly successful for treating neuropathic pain but its effect is limited for central origin pain caused by cord injury. The authors describe a case in which pain was successfully controlled by SCS implantation in a patient with intractable chronic neuropathic pain after T5 meningioma removal. The authors tried lead insertion over the T5 level passing through postoperative adhesions to produce adequate stimulation to the patient's painful areas fully enough without any complications. This case showed good response to SCS even though it was a central type of neuropathic pain by spinal cord injury.

Comparison of bispectral index (BIS) and entropy in patients with cerebral palsy during sevoflurane induction.

BACKGROUND: Demand of anesthesia for patients with cerebral palsy is more increasing. But there is still lacking in clinical research regarding how BIS and entropy reflect well on sedative and hypnotic state in patients with cerebral palsy. METHODS: Fifteen patients with cerebral palsy (Group CP) and fifteen patients without cerebral palsy (Group NL) scheduled for elective orthopedic surgery were included in the study. Induction of anesthesia was done by having the patient inhale 1 vol% sevoflurane and 100% oxygen using a total fresh gas flow of 8 L/min. Simultaneously BIS, state entropy (SE), response entropy (RE), end-tidal sevoflurane concentration were recorded every 15 seconds till there was no self respiration. When end-tidal sevoflurane concentration had not risen any more for 30 seconds, we increased inhaled sevoflurane concentration in 1 vol% increments. End point of recording was when self respiration was lost or the time sevoflurane concentration reached 8 vol%. RESULTS: No significant differences in RE, SE, BIS at baseline and end point were found between the two groups. No significant difference in the time reach end point was found between the two groups. BIS, SE and RE correlated with end-tidal sevoflurane concentration in the two groups. CONCLUSIONS: The authors found no significant difference in the entropy values between patients with CP and normal patients. Also, the entropy values could be interpreted like BIS in patients with CP. And BIS showed a stronger correlation with end tidal sevoflurane concentrations than entropy.

Oxidative damages in the DNA, lipids, and proteins of rats exposed to isofluranes and alcohols.

DNA damage, lipid peroxidation and protein oxidation were evaluated in rats exposed to a 1% isoflurane atmosphere with or without alcohol administration (administrated by gastric intubation at 4 g/kg body weight as a 50% solution). Single cell gel electrophoresis assays were performed in order to evaluate DNA damage occurring in the lymphocytes, spleen, bone marrow, brain, livers and lung of rats exposed to 1% isoflurane for 30 or 60 min with/without ethanol. Levels of malondialdehydes (MDA), a metabolite of lipid peroxidation, were determined in plasma and tissues. Carbonyl contents were also analyzed to determine levels of protein oxidation in plasma and tissues. Levels of DNA damage in lymphocytes, bone marrow, and the organ tissues of rats exposed to isoflurane were found to increase time dependently, and alcohol increased DNA damage. Lipid peroxidation and protein oxidation results showed patterns that differed from those of DNA damage. Levels of MDA in plasma, bone marrow, spleen, and the livers of rats exposed to isoflurane with/without ethanol were found to be time dependently increased, but this was not observed in the brain or lung. However, protein oxidation levels were significantly increased in the plasma, brains, and lungs of rats exposed to isoflurane, and exposure to isoflurane and alcohol, significantly increased these levels in plasma and brain. The present study demonstrates that isoflurane exposure results in significant DNA damage in rat lymphocytes, bone marrow, spleen, brain, livers, and lung. Moreover, alcohol was found to be as a strong inducer of DNA damage, lipid peroxidation and protein oxidation. However, no evidence in association between DNA damage, lipid peroxidation and protein oxidation was found. Regarding the effects of isoflurane and alcohol on oxidative damages, single strand DNA damages may be a useful biomarkers and blood cells and plasma appear to be more sensitive targets to oxidative damage than other tissues.