The impact of sevoflurane anesthesia on postoperative renal function: a systematic review and meta-analysis of randomized-controlled trials.

PURPOSE: Renal damage secondary to fluoride ions and compound A (CpdA) after sevoflurane anesthesia remains unclear. For safety reasons, some countries still recommend minimum fresh-gas flows (FGFs) with sevoflurane. We review the evidence regarding the intraoperative use of sevoflurane for anesthesia maintenance and postoperative renal function compared with other anesthetic agents used for anesthetic maintenance. Secondarily, we examine the effects of peak plasma fluoride and CpdA levels and the effect of FGF and duration of anesthesia on these parameters. SOURCE: The databases of MEDLINE (OVID and Pubmed), EMBASE, the Cochrane Library, Health Technology Assessment Database, CINAHL, and Web of Science were searched from inception until 23 April 2020 to identify randomized-controlled trials (RCTs) in humans utilizing sevoflurane or an alternative anesthetic for anesthesia maintenance with subsequent measurements of renal function. Two different paired reviewers independently selected the studies and extracted data. The quality of the evidence was appraised using GRADE recommendations. PRINCIPAL FINDINGS: Of 3,766 publications screened, 41 RCTs in human patients were identified. There was no difference between creatinine at 24 hr (21 studies; n = 1,529), or creatinine clearance (CCR) at 24 hr (12 studies; n = 728) in the sevoflurane vs alternative anesthetic groups. Peak fluoride and fluoride measured at 24 hr were higher with sevoflurane compared with other inhaled anesthetics. Subgroup analyses for sevoflurane usage in various contexts showed no significant difference between sevoflurane and alternative anesthetics for creatinine or CCR at 24 hr at varying FGF, duration of exposure, baseline renal function, or absorbent use. CONCLUSIONS: We did not find any association between the use of sevoflurane and postoperative renal impairment compared with other agents used for anesthesia maintenance. The scientific basis for recommending higher FGF with the use of sevoflurane needs to be revisited.

RéSUMé: OBJECTIF: Les lésions rénales secondaires aux ions fluorure et au composé A (CpdA) après une anesthésie au sévoflurane demeurent incertaines. Pour des raisons de sécurité, certains pays recommandent encore des débits de gaz frais (DGF) minimaux lors de l'utilisation du sévoflurane. Nous avons passé en revue les données probantes concernant l'utilisation peropératoire de sévoflurane pour le maintien de l'anesthésie sur la fonction rénale postopératoire comparativement à d'autres agents anesthésiques utilisés pour le maintien de l'anesthésie. En analyse secondaire, nous avons examiné les effets des taux plasmatiques maximaux de fluorure et de CpdA et l'effet du DGF et de la durée de l'anesthésie sur ces paramètres. SOURCE: Des recherches ont été menées dans les bases de données de MEDLINE (OVID et Pubmed), EMBASE, the Cochrane Library, Health Technology Assessment Database, CINAHL et Web of Science, de leur création jusqu'au 23 avril 2020. Nous y avons identifié les études randomisées contrôlées (ERC) réalisées sur des sujets humains utilisant du sévoflurane ou un agent anesthésique alternatif pour le maintien de l'anesthésie et présentant des mesures subséquentes de la fonction rénale. Deux différents réviseurs appariés ont sélectionné de manière indépendante les études et extrait les données. La qualité des données probantes a été évaluée à l'aide des recommandations GRADE. CONSTATATIONS PRINCIPALES: Parmi les 3766 publications passées en revue, 41 ERC réalisées chez des patients humains ont été identifiées. Aucune différence n'a été observée en ce qui touchait à la valeur de créatinine à 24 h (21 études; n = 1529) ou de la clairance de la créatinine (CCR) à 24 h (12 études; n = 728) dans les groupes sévoflurane vs autres anesthésiques. Les taux maximaux de fluorure et le fluorure mesuré à 24 h étaient plus élevés lors de l'utilisation de sévoflurane que d'autres agents anesthésiques halogénés. Les analyses de sous-groupe portant sur l'utilisation du sévoflurane dans divers contextes n'ont démontré aucune différence significative entre le sévoflurane et les autres anesthésiques en matière de valeur de créatinine ou de CCR à 24 h selon différents DGF, durées d'exposition, fonctions rénales de base ou absorbants. CONCLUSION: Nous n'avons pas trouvé d'association entre l'utilisation du sévoflurane et des détériorations de la fonction rénale postopératoires par rapport aux autres agents utilisés pour le maintien de l'anesthésie. Les raisons scientifiques sur lesquelles repose la recommandation d'un DGF plus élevé lors de l'utilisation de sévoflurane doivent être réexaminées.

Health Risk Assessment for Inhalation Exposure to Methyl Tertiary Butyl Ether at Petrol Stations in Southern China.

Methyl tertiary butyl ether (MTBE), a well known gasoline additive, is used in China nationwide to enhance the octane number of gasoline and reduce harmful exhaust emissions, yet little is known regarding the potential health risk associated with occupational exposure to MTBE in petrol stations. In this study, 97 petrol station attendants (PSAs) in southern China were recruited for an assessment of the health risk associated with inhalation exposure to MTBE. The personal exposure levels of MTBE were analyzed by Head Space Solid Phase Microextraction GC/MS, and the demographic characteristics of the PSAs were investigated. Cancer and non-cancer risks were calculated with the methods recommended by the United States Environmental Protection Agency. The results showed that the exposure levels of MTBE in operating workers were much higher than among support staff (p < 0.01) and both were lower than 50 ppm (an occupational threshold limit value). The calculated cancer risks (CRs) at the investigated petrol stations was 0.170 to 0.240 per 106 for operating workers, and 0.026 to 0.049 per 106 for support staff, which are below the typical target range for risk management of 1 × 10(-6) to 1 × 10(-4); The hazard quotients (HQs) for all subjects were <1. In conclusion, our study indicates that the MTBE exposure of PSAs in southern China is in a low range which does not seem to be a significant health risk.

Delayed onset of suspected malignant hyperthermia during sevoflurane anesthesia in an Afghan trauma patient: a case report.

Malignant hyperthermia (MH) is a rare pathologic hypermetabolic pharmacogenetic disorder of skeletal muscle calcium regulation following exposure to depolarizing muscle relaxants and/or volatile anesthetics. Although its pathogenesis is relatively well understood, there is wide variability in both the time of onset and the presentation of clinical signs and symptoms. In some circumstances the delayed onset of the hypermetabolic state may hinder timely recognition and treatment. Differential diagnosis of an MH crisis can be particularly challenging in a trauma patient, especially in an austere environment. This case report describes the presentation and management of a suspected case of MH in an Afghan national who underwent surgery following lower extremity trauma resulting from an improvised explosive device.

Efficiency and safety of inhalative sedation with sevoflurane in comparison to an intravenous sedation concept with propofol in intensive care patients: study protocol for a randomized controlled trial.

BACKGROUND: State of the art sedation concepts on intensive care units (ICU) favor propofol for a time period of up to 72 h and midazolam for long-term sedation. However, intravenous sedation is associated with complications such as development of tolerance, insufficient sedation quality, gastrointestinal paralysis, and withdrawal symptoms including cognitive deficits. Therefore, we aimed to investigate whether sevoflurane as a volatile anesthetic technically implemented by the anesthetic-conserving device (ACD) may provide advantages regarding 'weaning time', efficiency, and patient's safety when compared to standard intravenous sedation employing propofol. METHOD/DESIGN: This currently ongoing trial is designed as a two-armed, monocentric, randomized prospective phase II study including intubated intensive care patients with an expected necessity for sedation exceeding 48 h. Patients are randomly assigned to either receive intravenous sedation with propofol or sevoflurane employing the ACD. Primary endpoint is the comparison of the 'weaning time' defined as the time required from discontinuation of the sedating agent until sufficient spontaneous breathing occurs. Moreover, sedation depth evaluated by Richmond Agitation Sedation Scale and parameters of patient's safety (that is, vital signs, laboratory monitoring of organ function) as well as the duration of mechanical ventilation and overall stay on the ICU are analyzed and compared. An intention-to-treat analysis will be carried out with all patients for whom it will be possible to define a wake-up time. In addition, a per-protocol analysis is envisaged. Completion of patient recruitment is expected by the end of 2012. DISCUSSION: This clinical study is designed to evaluate the impact of sevoflurane during long-term sedation of critically ill patients on 'weaning time', efficiency, and patient's safety compared to the standard intravenous sedation concept employing propofol. TRIAL REGISTRATION: EudraCT2007-006087-30; ISRCTN90609144.

Halothane: how should it be used in a developing country?

The anaesthetic agent halothane is still widely used in developing countries including the Islamic Republic of Iran because of its low price. Because of halothane-induced hepatitis, a rare complication, it has been replaced by other inhalation anaesthetics in Western countries; it has been suggested by some Iranian professionals that the Islamic Republic of Iran should do the same. We evaluated various dimensions of this replacement through a literature review to assess the incidence of halothane-induced hepatitis and costs of anaesthetics in the country. We also conducted a questionnaire survey of 30 anaesthesiology/gastroenterology experts about their views on the subject. The results indicate that the incidence of halothane hepatitis in the Islamic Republic of Iran is very low and could mostly be avoided by strict adherence to guidelines. Complete withdrawal of halothane in the Islamic Republic of Iran might not be appropriate at present. Comprehensive cost-effectiveness studies are needed before a decision is made on complete replacement of halothane with other anaesthetics.

Avaliação da indução, recuperação, agitação ao despertar e consumo com uso de duas marcas de sevoflurano para anestesia ambulatorial / Assessment of induction, recovery, agitation upon awakening, and consumption with the use of two brands of sevoflurane for ambulatory anesthesia / Evaluación de la inducción, recuperación, agitación al despertar y consumo con el uso de dos marcas de sevoflurano para la anestesia ambulatorial

JUSTIFICATIVA E OBJETIVOS: O sevoflurano por suas características farmacológicas é o anestésico ideal para procedimentos de curta duração. Existem duas marcas de sevoflurano no mercado brasileiro, o Sevocris® e Sevorane®, com diferentes formulações e envasamento. O objetivo deste estudo foi analisar se existem diferenças entre os dois anestésicos na indução, manutenção, recuperação e consumo. MÉTODO: Foram incluídas 130 crianças dividas em dois grupos segundo a marca do agente utilizado: Grupo 1 sevoflurano da Cristália® e Grupo 2 da Abbott®. Foram analisados os seguintes parâmetros: frequência cardíaca, pressão arterial sistólica e diastólica, fração inspirada e expirada de sevoflurano, valores de BIS, temperatura timpânica, tempos de indução e recuperação, agitação ao despertar pela escala PAED e consumo do anestésico por pesagem dos vaporizadores. A indução foi realizada com 1 CAM e incrementadas a cada três movimentos respiratórios em 0,5 CAM, até no máximo 3 CAM. RESULTADO: Não houve diferença entre os grupos quanto ao tempo de procedimento e de anestesia e nos parâmetros avaliados na indução. No Grupo 1, o número de crianças que necessitaram bolus adicionais de sevoflurano na manutenção da anestesia foi maior que no 2 (p < 0,05). A fração inspirada e expirada de sevoflurano no final do procedimento foi menor no Grupo 1 (p < 0,001). No momento do despertar o valor do BIS foi menor no Grupo 1 (p = 0,045). Outros parâmetros avaliados na recuperação não mostraram diferença entre os grupos. O consumo de anestésico foi semelhante entre os grupos.

BACKGROUND AND OBJECTIVES: Due to its pharmacological characteristics, sevoflurane is the ideal anesthetic for short-duration procedures. There are two brands of sevoflurane in the Brazilian market, Sevocris® and Sevorane®, with different formulations and packaging. The objective of this study was to assess whether there are differences between the two anesthetics regarding induction, maintenance, recovery, and consumption. METHODS: One hundred and thirty children were included, divided into two groups according to the brand used: Group 1 was assigned to sevoflurane Cristália® and Group 2 to sevoflurane Abbott®. The following parameters were assessed: heart rate, systolic and diastolic blood pressure, fraction of inspired and expired sevoflurane, BIS values, tympanic temperature, induction and recovery time, agitation upon awakening measured by the PAED scale, and anesthetic consumption by weighing the vaporizers. Anesthesia was induced with 1 MAC and increased every three breaths at 0.5 MAC, up to 3 MAC. RESULTS: There was no difference between groups regarding the duration of the procedure, the anesthesia, and the parameters evaluated at induction. In Group 1, the number of children who required additional bolus of sevoflurane for anesthesia maintenance was higher than in Group 2 (p < 0.05). The fraction of inspired and expired sevoflurane at the end of the procedure was lower in Group 1 (p < 0.001). Upon awakening, BIS value was lower in Group 1 (p = 0.045). Other parameters evaluated in recovery showed no difference between groups. The use of anesthesia was similar between groups.

JUSTIFICATIVA Y OBJETIVOS: El sevoflurano, por sus características farmacológicas, es el anestésico ideal para procedimientos de corta duración. Existen dos marcas de sevoflurano en el mercado brasileño, el Sevocris® y el Sevorane®, con diferentes formulaciones y envases. El objetivo de este estudio, fue analizar si existen diferencias entre los dos anestésicos en la inducción, mantenimiento, recuperación y consumo. MÉTODO: Se incluyeron 130 niños divididos en dos grupos según la marca del agente utilizado: Grupo 1 sevoflurano de Cristália® y Grupo 2 de Abbott®. Se analizaron los siguientes parámetros: frecuencia cardíaca, presión arterial sistólica y diastólica, fracción inspirada y espirada de sevoflurano, valores de BIS, temperatura timpánica, tiempos de inducción y recuperación, agitación al despertar por la escala PAED, y consumo del anestésico por pesaje de los vaporizadores. La inducción fue realizada con 1 CAM e incrementada a cada tres movimientos respiratorios en 0,5 CAM, hasta el máximo de 3 CAM. RESULTADO: No hubo diferencia entre los grupos en cuanto al tiempo de procedimiento y de anestesia y en los parámetros evaluados en la inducción. En el Grupo 1, el número de niños que necesitaron bolos adicionales de sevoflurano en el mantenimiento de la anestesia, fue mayor que en el 2 (p < 0,05). La fracción inspirada y espirada de sevoflurano al final del procedimiento fue menor en el Grupo 1 (p < 0,001). Al momento del despertar, el valor del BIS fue menor en el Grupo 1 (p = 0,045). Otros parámetros evaluados en la recuperación no arrojaron diferencia entre los grupos. El consumo de anestésico fue similar entre los grupos.

Assessment of induction, recovery, agitation upon awakening, and consumption with the use of two brands of sevoflurane for ambulatory anesthesia.

BACKGROUND AND OBJECTIVES: Due to its pharmacological characteristics, sevoflurane is the ideal anesthetic for short-duration procedures. There are two brands of sevoflurane in the Brazilian market, Sevocris® and Sevorane®, with different formulations and packaging. The objective of this study was to assess whether there are differences between the two anesthetics regarding induction, maintenance, recovery, and consumption. METHODS: One hundred and thirty children were included, divided into two groups according to the brand used: Group 1 was assigned to sevoflurane Cristália® and Group 2 to sevoflurane Abbott®. The following parameters were assessed: heart rate, systolic and diastolic blood pressure, fraction of inspired and expired sevoflurane, BIS values, tympanic temperature, induction and recovery time, agitation upon awakening measured by the PAED scale, and anesthetic consumption by weighing the vaporizers. Anesthesia was induced with 1 MAC and increased every three breaths at 0.5 MAC, up to 3 MAC. RESULTS: There was no difference between groups regarding the duration of the procedure, the anesthesia, and the parameters evaluated at induction. In Group 1, the number of children who required additional bolus of sevoflurane for anesthesia maintenance was higher than in Group 2 (p<0.05). The fraction of inspired and expired sevoflurane at the end of the procedure was lower in Group 1 (p<0.001). Upon awakening, BIS value was lower in Group 1 (p=0.045). Other parameters evaluated in recovery showed no difference between groups. The use of anesthesia was similar between groups.

[Efficacy, safety and cost of sedation with sevoflurane in intensive care unit]. / Efficacité, tolérance et coût d'une sédation par sévoflurane en réanimation.

OBJECTIVES: To study efficacy, systemic and cerebral haemodynamic, and cost of sedation with sevoflurane after midazolam failure. STUDY DESIGN: Prospective observational study in a mixed intensive care unit. PATIENTS AND METHODS: Mechanically ventiled patients in whom deep sedation failed (Ramsay score<5 despite midazolam 10mg/h and fentanyl 400µg/h) were enrolled. Sedation with sevoflurane and fentanyl (200µg/h) was performed during 48 hours. Sevoflurane was administered with a dedicated filter (AnaConDa™) and sevoflurane infusion rate was adjusted in order to achieve a Ramsay score ≥5. Ramsay score, mean arterial blood pressure, norepinephrine dose/24h, intracranial pressure and cerebral perfusion pressure in patients with brain injury were measured. Directs costs for sedation were calculated. An analysis of variance for repeated measures compared values between D0 (intravenous sedation), D1 and D2 (inhaled sedation). RESULTS: Twenty-five patients (age=51 [38-63], SAPS II=43 [33-49]) were enrolled. Ramsay score was 4 [4,5] at D0 and 6 [6] at D1 and D2 (P<0.05 vs D0). Mean arterial pressure was significantly lower at D1 (80 [73-86] mmHg) as compared to D0 (84 [77-92] mmHg) and D2 (84 [78-91] mmHg) (P<0,05). Norepinephrine consumption was lower at D2 as compared to D1 (P<0,05). Intracranial pressure was lower at D1 (9 [5-13] mmHg) and D2 (11 [7-15] mmHg) as compared to D0 (12 [7-17] mmHg) (P<0.05). PPC was stable at D1 and increased at D2. Directs costs were significantly increased with sevoflurane. CONCLUSION: Sevoflurane is an effective and safe alternative to midazolam in ICU patients associated with a moderate increase in costs.

Formaldehyde-releasers in cosmetics: relationship to formaldehyde contact allergy. Part 2. Patch test relationship to formaldehyde contact allergy, experimental provocation tests, amount of formaldehyde released, and assessment of risk to consumers allergic to formaldehyde.

This is the second part of an article on formaldehyde-releasers in cosmetics. The patch test relationship between the releasers in cosmetics to formaldehyde contact allergy is reviewed and it is assessed whether products preserved with formaldehyde-releasers may contain enough free formaldehyde to pose a threat to individuals with contact allergy to formaldehyde. There is a clear relationship between positive patch test reactions to formaldehyde-releasers and formaldehyde contact allergy: 15% of all reactions to 2-bromo-2-nitropropane-1,3-diol and 40-60% of the reactions to the other releasers are caused by a reaction to the formaldehyde in the test material. There is only fragmented data on the amount of free formaldehyde in cosmetics preserved with formaldehyde donors. However, all releasers (with the exception of 2-bromo-2-nitropropane-1,3-diol, for which adequate data are lacking) can, in the right circumstances of concentration and product composition, release >200 p.p.m. formaldehyde, which may result in allergic contact dermatitis. Whether this is actually the case in any particular product cannot be determined from the ingredient labelling. Therefore, we recommend advising patients allergic to formaldehyde to avoid leave-on cosmetics preserved with quaternium-15, diazolidinyl urea, DMDM hydantoin, or imidazolidinyl urea, acknowledging that many would tolerate some products.

[Propofol triggers a marked body temperature increase in a patient with fulminant malignant hyperthermia (MH) without inducing other symptoms of MH].

A 53-year-old woman who had experienced symptoms of fulminant malignant hyperthermia (MH) by sevoflurane a week before and her MH muscle biopsy revealing positive later, underwent the right hemicolectomy under total intravenous anesthesia with propofol and fentanyl. The patient's body temperature increased at a rate of 0.6 degree C per 15 min from 37.5 to 39.4 degrees C, but other symptoms of MH, such as tachycardia, arrhythmia, acidemia, and hypoxemia, were obviously slight in comparison with those induced by sevoflurane. The body temperature decreased after discontinuation of propofol and administration of dantrorene injection. When the patient received continuous propofol infusion for the purpose of sedation in the intensive care unit again, the body temperature gradually increased to 40 degrees C. However, it decreased to 37.8 degrees C after discontinuation of propofol and dantrorene injection again. It is well recognized that propofol is not a MH trigger, but it shoud be noted that some MH patients could experience a hypermetabolic state, such as hyperthermia, even by propofol.

Assessment of cardiac troponin I and C-reactive protein concentrations associated with anesthetic protocols using sevoflurane or a combination of fentanyl, midazolam, and sevoflurane in dogs.

OBJECTIVE: To report serum cardiac troponin I (cTnI) and C-reactive protein (CRP) concentrations in dogs anesthetized for elective surgery using two anesthetic protocols. STUDY DESIGN: Prospective, randomized clinical study. ANIMALS: Twenty client-owned dogs presenting for elective ovariohysterectomy or castration. METHODS: The dogs were randomized into two groups. All dogs were premedicated with glycopyrrolate (0.011 mg kg(-1)) and hydromorphone (0.1 mg kg(-1)) i.m. approximately 30 minutes prior to induction of anesthesia. Anesthesia in dogs in group 1 was induced with propofol (6 mg kg(-1)) i.v. to effect and in dogs in group 2 with diazepam (0.2 mg kg(-1)) i.v. followed by etomidate (2 mg kg(-1)) i.v. to effect. For maintenance of anesthesia, group 1 received sevoflurane (adjustable vaporizer setting 0.5-4%) and group 2 received a combination of fentanyl (0.8 microg kg(-1) minute(-1)) and midazolam (8.0 microg kg(-1) minute(-1)) i.v. plus sevoflurane (adjustable vaporizer setting 0.5-4%) to maintain anesthesia. Serum cTnI and CRP concentrations were measured at baseline and 6, 18, and 24 hours post-anesthetic induction. Biochemical analysis was performed at baseline. Lactate was obtained at baseline and 6 hours post-anesthetic induction. Heart rate and mean arterial blood pressure were measured intra-operatively. RESULTS: Baseline serum cTnI and CRP concentrations were comparable between groups. A significant difference in serum cTnI or CRP concentrations was not detected post-operatively between groups at any time point. Serum CRP concentrations were significantly increased post-anesthetic induction in both groups, which was attributed to surgical trauma. CONCLUSIONS AND CLINICAL RELEVANCE: There was no significant difference in serum cTnI and CRP concentrations between anesthetic protocols. Further investigation in a larger number of dogs is necessary to confirm the current findings.

Anaesthesiological strategies in elective craniotomy: randomized, equivalence, open trial--the NeuroMorfeo trial.

BACKGROUND: Many studies have attempted to determine the "best" anaesthetic technique for neurosurgical procedures in patients without intracranial hypertension. So far, no study comparing intravenous (IA) with volatile-based neuroanaesthesia (VA) has been able to demonstrate major outcome differences nor a superiority of one of the two strategies in patients undergoing elective supratentorial neurosurgery. Therefore, current practice varies and includes the use of either volatile or intravenous anaesthetics in addition to narcotics. Actually the choice of the anaesthesiological strategy depends only on the anaesthetists' preferences or institutional policies. This trial, named NeuroMorfeo, aims to assess the equivalence between volatile and intravenous anaesthetics for neurosurgical procedures. METHODS/DESIGN: NeuroMorfeo is a multicenter, randomized, open label, controlled trial, based on an equivalence design. Patients aged between 18 and 75 years, scheduled for elective craniotomy for supratentorial lesion without signs of intracranial hypertension, in good physical state (ASA I-III) and Glasgow Coma Scale (GCS) equal to 15, are randomly assigned to one of three anaesthesiological strategies (two VA arms, sevoflurane + fentanyl or sevoflurane + remifentanil, and one IA, propofol + remifentanil). The equivalence between intravenous and volatile-based neuroanaesthesia will be evaluated by comparing the intervals required to reach, after anaesthesia discontinuation, a modified Aldrete score > or = 9 (primary end-point). Two statistical comparisons have been planned: 1) sevoflurane + fentanyl vs. propofol + remifentanil; 2) sevoflurane + remifentanil vs. propofol + remifentanil. Secondary end-points include: an assessment of neurovegetative stress based on (a) measurement of urinary catecholamines and plasma and urinary cortisol and (b) estimate of sympathetic/parasympathetic balance by power spectrum analyses of electrocardiographic tracings recorded during anaesthesia; intraoperative adverse events; evaluation of surgical field; postoperative adverse events; patient's satisfaction and analysis of costs. 411 patients will be recruited in 14 Italian centers during an 18-month period. DISCUSSION: We presented the development phase of this anaesthesiological on-going trial. The recruitment started December 4th, 2007 and up to 4th, December 2008, 314 patients have been enrolled.

Low fresh gas flow balanced anesthesia versus target controlled intravenous infusion anesthesia in laparoscopic cholecystectomy: a cost-minimization analysis.

BACKGROUND: Laparoscopic surgery is widely recognized as a well-tolerated and effective method for cholecystectomy. It is also considered cost saving because it has been associated with a decreased hospital length of stay. Variables that might lead to increased costs in laparoscopic surgery are the technique and drugs used in anesthesia. OBJECTIVE: The goal of this study was to compare the costs of 2 anesthetic techniques used in laparoscopic cholecystectomy (LC)--balanced versus IV anesthesia--from the standpoint of an outpatient surgical department, with a time horizon of 1 year. METHODS: Patients scheduled to undergo elective LC were enrolled in this prospective case study. Patients were randomly allocated to receive balanced anesthesia, administered as low fresh gas flow (LFGF) with inhalational sevoflurane and IV sufentanil in a target controlled infusion (LFGF SS group), or IV anesthesia, administered as IV propofol/sufentanil in a target controlled infusion (TCI group). We used a microcosting procedure to measure health care resource utilization in individual patients to detect treatment differences. The costs of medications used for the induction and maintenance of anesthesia during surgery were considered for LFGF SS and TCI. Other end points included duration of anesthesia; mean times to early emergence, tracheal extubation, orientation, and postanesthesia discharge (PAD); pain intensity before first analgesia; number of analgesics required in the first 24 hours after surgery; and prevalences of nausea, vomiting, and agitation. RESULTS: A total of 60 patients were included in this analysis (male/female ratios in the LFGF SS and TCI groups: 11/19 and 12/18, respectively; mean [SD] ages, 48 [7.9] and 47 [8.6] years; and mean [SD] body mass indexes, 26 [2.0] and 26 [3.0] kg/m2). The costs of anesthetics were significantly lower with LFGF SS compared with TCI (euro17.40 [euro2.66] vs euro22.01 [euro2.50] [2006 euros]). Times to early emergence and tracheal extubation were significantly shorter with LFGF SS than TCI (5.97 [1.16] vs 7.73 [1.48] minutes and 7.57 [1.07] vs 8.87 [1.45] minutes, respectively). There were no significant between-group differences in mean duration of anesthesia; times to orientation and PAD; pain intensity before first analgesia; number of analgesics required in the first 24 hours; or prevalences of nausea, vomiting, and agitation. Because no clinically significant differences in the anesthetic results were observed, a cost-minimization analysis was conducted and found that using LFGF SS, the outpatient surgical department could realize a budget savings of euro454 per 100 patients. For the nearly 1000 expected patients per year, the savings for the department was calculated as euro4540. CONCLUSION: The results from this cost analysis in these patients who underwent elective LC suggest that the use of sevoflurane through the LFGF technique would be cost saving in this outpatient surgical department.

Incidence and risk factors of emergence agitation in pediatric patients after general anesthesia.

OBJECTIVE: To study the incidence and evaluate factors associated with emergence agitation (EA) in pediatrics after general anesthesia. MATERIAL AND METHOD: A prospective observational study was conducted in 250 pediatric patients aged 2-9 years, who received general anesthesia for various operative procedures in Maharaj Nakorn Chiang Mai Hospital between October 2006 and September 2007. The incidence of EA was assessed Difficult parental-separation behavior, pharmacologic and non-pharmacologic interventions, and adverse events were also recorded Univariate and multivariate analysis were used to determine the factors associated with EA. A p-value of less than 0.05 was considered significant. RESULTS: One hundred and eight children (43.2%) had EA, with an average duration of 9.6 +/- 6.8 minutes. EA associated with adverse events occurred in 32 agitated children (29.6%). From univariate analysis, factors associated with EA were difficult parental-separation behavior, preschool age (2-5 years), and general anesthesia with sevoflurane. However; difficult parental-separation behavior; and preschool age were the only factors significantly associated with EA in the multiple logistic regression analysis with OR = 3.021 (95% CI = 1.680, 5.431, p < 0.001) and OR = 1.857 (95% CI = 1.075, 3.206, p = 0.026), respectively. CONCLUSION: The present study indicated that the incidence of EA was high in PACU. Preschool children and difficult parental-separation behavior were the predictive factors of agitation on emergence. Therefore, anesthesia personnel responsible for pediatric anesthesia should have essential skills and knowledge to effectively care for children before, during, and after an operation, including implementing the methods that minimize incidence of EA.

Sevoflurane provides earlier tracheal extubation and assessment of cognitive recovery than isoflurane in patients undergoing off-pump coronary artery bypass surgery.

OBJECTIVE: To determine whether sevoflurane, because of its lower blood/gas partition coefficient, compared with isoflurane as the primary anesthetic agent, allows earlier tracheal extubation and assessment of cognitive function after off-pump coronary artery bypass (OPCAB) surgery. DESIGN: Prospectively, patients were randomly assigned to receive sevoflurane or isoflurane as their primary anesthetic. Intraoperative opioids were limited to 5 microg/kg of fentanyl. SETTING: Two university hospitals with active cardiac surgery programs. PARTICIPANTS: One hundred one OPCAB surgery patients who met inclusionary and exclusionary criteria participated with institutional review board approval. INTERVENTIONS: Mini-Mental Status Examination, Memory Recall Test, and Observer Assessment of Anxiety and Sedation scales were administered preoperatively, postextubation, at 90 minutes, and between 12 to 24 hours. Pain scores were obtained every 15 minutes after extubation for 90 minutes. MEASUREMENTS AND MAIN RESULTS: Sevoflurane patients were extubated earlier than isoflurane patients (Sevo, 176 +/- 217 minutes and Iso, 257 +/- 279 min, p = 0.02). Although both agents produced similar postanesthetic cognitive profiles, cognitive testing occurred approximately 90 minutes earlier in the sevoflurane group. Verbal rating scale for pain scores >5 were more frequent for sevoflurane than isoflurane patients (p = 0.03). CONCLUSIONS: Both sevoflurane and isoflurane may be safely used as maintenance agents in OPCAB. Sevoflurane has the advantage of allowing earlier extubation and evaluation of cognitive and neurologic function after OPCAB.

[Case of malignant hyperthermia in which treatment was carried out smoothly].

We experienced a case of the abortive malignant hyperthermia (MH) that had developed during operation. The patient was a 14-year-old girl, and plastic surgery was scheduled under general anesthesia. Serum creatine kinase (CK) levels were high with 505 IU x l(-1) at the preoperative examination. General anesthesia was induced with propofol and vecuronium bromide, and maintained with sevoflurane. Suddenly, sinus tachycardia of an uncertain cause and a rapid rise of end-tidal carbon dioxide (Et(CO2)) concentration were noticed. Since we suspected MH, we did cooling and hyperventilation and administered dantrolene sodium 2 mg x kg(-1) for the patient. As a result, the highest temperature remained at 37.6 degrees C. Serum CK levels increased most postoperative 18 hours later and it is improved gradually. As sevoflurane, promotes the CICR (calcium-induced calcium release) mechanism, the trigger of this case is probably sevoflurane. As for the symptom that makes us doubt MH first, there is a maked rapid rises of Et(CO2). Therefore, it is important monitor and recognize the first symptom of MH.

Exposure reconstruction for reducing uncertainty in risk assessment: example using MTBE biomarkers and a simple pharmacokinetic model.

Adverse health risks from environmental agents are generally related to average (long-term) exposures. Because a given individual's contact with a pollutant is highly variable and dependent on activity patterns, local sources and exposure pathways, simple 'snapshot' measurements of surrounding environmental media may not accurately assign the exposure level. Furthermore, susceptibility to adverse effects from contaminants is considered highly variable in the population so that even similar environmental exposure levels may result in differential health outcomes in different individuals. The use of biomarker measurements coupled to knowledge of rates of uptake, metabolism and elimination has been suggested as a remedy for reducing this type of uncertainty. To demonstrate the utility of such an approach, we invoke results from a series of controlled human exposure tests and classical first-order rate kinetic calculations to estimate how well spot measurements of methyl tertiary butyl ether and the primary metabolite, tertiary butyl alcohol, can be expected to predict different hypothetical scenarios of previous exposures. We found that blood and breath biomarker measurements give similar results and that the biological damping effect of the metabolite production gives more stable estimates of previous exposure. We also explore the value of a potential urinary biomarker, 2-hydroxyisobutyrate suggested in the literature. We find that individual biomarker measurements are a valuable tool in reconstruction of previous exposures and that a simple pharmacokinetic model can identify the time frames over which an exogenous chemical and the related chemical biomarker are useful. These techniques could be applied to broader ranges of environmental contaminants to assess cumulative exposure risks if ADME (Absorption, Distribution, Metabolization and Excretion) is understood and systemic biomarkers can be measured.