Hipertermia maligna: a propósito de un caso / Malignant hyperthermia: a case report

Malignant hyperthermia (MH) is a rare neuromuscular hereditary disorder, triggered in susceptible individuals by exposure to inhalational agents or succinylcholine and manifested as a hypermetabolic state. We report the case of a 22 years old male patient anesthetized with Desflurane in whom MH was suspected because of unexplained increased levels of End-Tidal carbon dioxide. Dantrolene was administered with good response. Respiratory acidosis and hyperkalemia were also detected but could be easily controlled. The postoperative period was uneventful with the exception of a superficial venous thrombosis at the dantrolene’s injection site. The patient was discharged eight days after the episode without sequela. Successful management of a malignant hyperthemia episode must include: early suspicion, asking for help and early treatment with dantrolene.

La Hipertermia Maligna es un trastorno neuromuscular hereditario infrecuente, manifestado por un estado hipermetabólico desencadenado en individuos susceptibles por la exposición a anestésicos halogenados o Succinilcolina. Se reporta el caso de un hombre de 22 años anestesiado con Desflurano, en quien el diagnóstico de Hipertermia Maligna se sospechó por la presencia de elevación inexplicada del CO2 espirado, que respondió a la suspensión del Desflurano y administración de Dantroleno. Se observó además hiperkalemia y acidosis respiratoria, que fueron fácilmente compensadas. La evolución postoperatoria fue satisfactoria, a excepción de una trombosis venosa superficial en el sitio de inyección del Dantroleno. El paciente fue dado de alta al 8avo día postoperatorio, sin secuelas. Las claves del manejo exitoso de un episodio de hipertermia maligna están en: Sospecha precoz, solicitar ayuda e inició rápido del tratamiento con Dantroleno.

Operating room discharge after deep neuromuscular block reversed with sugammadex compared with shallow block reversed with neostigmine: a randomized controlled trial.

OBJECTIVE: To determine if reversing a deep or moderate block with sugammadex, compared with a shallow block reversed with neostigmine, reduces the time to operating room discharge after surgery and the time spent in the postanesthesia care unit. DESIGN: A randomized controlled trial. SETTING: Monocentric study performed from February 2011 until May 2012. PATIENTS: One hundred consenting women with American Society of Anesthesiologists grade I or II were randomized into 2 groups. INTERVENTION: Laparoscopic hysterectomy was performed under desflurane general anesthesia. For the neostigmine (N) group, 0.45 mg · kg-1 rocuronium was followed by spontaneous recovery. A 5-mg rescue bolus was administered only if surgical evaluation was unacceptable. At the end of surgery, 50 µg · kg-1 neostigmine with glycopyrrolate was administered. For the sugammadex (S) group, a higher intubating rocuronium dose (0.6 mg · kg-1) was followed by 5-mg boluses each time the train-of-four count exceeded 2. Sugammadex (2-4 mg · kg-1) was administered to reverse the block. All patients were extubated after obtaining a train-of-four ratio of 0.9. MEASUREMENTS: The duration between the end of surgery and operating room discharge and the time spent in the postanesthesia care unit. MAIN RESULTS: The time till operating room discharge was shorter and more predictable in group S (9.15±4.28 minutes vs 13.87±11.43 minutes in group N; P=.005). The maximal duration in group S was 22 minutes, compared with 72 minutes in group N. The time spent in the postanesthesia care unit was not significantly different (group S: 47.75±31.77 minutes and group N: 53.43±40.57 minutes; P=.543). CONCLUSION: Maintaining a deep neuromuscular block during laparoscopic hysterectomy reversed at the end of the procedure with sugammadex enabled a faster and more predictable time till operating room discharge than did the classical combination of a shallower block reversed with neostigmine.

Limiting the accessibility of cost-prohibitive drugs reduces overall anesthetic drug costs: a retrospective before and after analysis.

PURPOSE: Cost effectiveness is becoming increasingly important in today's healthcare environment. Remifentanil, dexmedetomidine, and desflurane are costly agents that often have suitable alternatives to their use. We sought to identify changes in cost and outcomes following interventions that limited the availability of these drugs. METHODS: We calculated anesthetic drug costs for all operating room procedures performed before and after the accessibility interventions. We retrospectively compared drug costs per case and the frequency of agent use before and after the interventions. In addition, we analyzed the incidence of adverse outcomes, including delayed out-of-room times, postoperative nausea and vomiting (PONV), unplanned intubations, use of naloxone, and reintubations. Wilcoxon-Mann-Whitney and Chi square analyses were used to quantify differences in cost, use, and outcomes between cohorts. RESULTS: Of the 27,233 cases we identified, 24,201 cases were analyzed. The mean anesthetic drug costs per case were significantly lower after the interventions vs before at ($21.44 vs $32.39, respectively), a cost savings of $10.95 (95% confidence interval, $9.86 to $12.04; P < 0.001). Additionally, a comparison of data after vs before the interventions revealed the following results: remifentanil use was significantly lower (3.5% vs 9.2% of cases; P < 0.001). Dexmedetomidine use did not differ significantly (0.4% vs 0.5% of cases; P = 0.07), and desflurane use was significantly lower (0.6% vs 20.2% of cases; P < 0.001). There was no significant relationship between the interventions and the frequency of delayed out-of-room times (15.5% vs 15.9%; P = 0.41), unplanned intubations (0.02% vs 0.03%; P = 0.60), and reintubations (0.01% vs 0.03%; P = 0.28). Postoperative nausea and vomiting decreased significantly after the interventions (22.8% vs 24.4%; P = 0.003), and naloxone use showed a significant increase (0.22% vs 0.11% of cases; P = 0.04). CONCLUSIONS: Reducing the accessibility of these cost-prohibitive agents resulted in significant anesthetic drug cost savings and decreased utilization of remifentanil and desflurane. The interventions had no significant effect on patient recovery time, incidence of unplanned intubations, or incidence of reintubation, but they were associated with a decrease in PONV and an increase in naloxone use.

Reliability of the volatile agent consumption display in the Draeger Primus™ anesthesia machine.

Knowledge of the consumed amount of volatile anesthetic (VA) expressed in liquid agent is necessary to enable agent sparing dosing measures and for billing purposes. The widespread Draeger Primus™ anesthesia machine displays in its logbook the amount of consumed VA at the end of each anesthesia, but the reliability of this parameter is yet unknown. The objective was to evaluate the precision and reliability of the inbuilt VA consumption display in Draeger Primus™ anesthesia machines as compared with the gold standard of weighing the vaporizer before and after anesthesia. In this prospective laboratory investigation we compared the VA consumption displayed by the Draeger Primus™ anesthesia machine with measured vaporizer weight differences before and after 10 sevoflurane and 10 desflurane anesthesias. We assessed the average difference and spread of values between the predicted (displayed) and measured (control) values for VA consumption. The displayed sevoflurane consumption overestimated the measured values by 4.3 ± 5.4 ml (7.6%). The displayed desflurane consumption underestimated the measured values by -3.5 ± 6.3 ml (6.2%). Nine from 10 sevoflurane pairs of values and all desflurane pairs of values were within ±1.96 SD. The displayed VA consumption calculations for sevoflurane and desflurane in the Draeger Primus™ are sufficiently reliable to estimate the pharmacoeconomic impact of VA delivery during inhalational anesthesia.

Effect of transversus abdominis plane block on cost of laparoscopic cholecystectomy anesthesia.

BACKGROUND: Use of transversus abdominis plane (TAP) block for postoperative analgesia is continuously increasing. However, few studies have investigated intraoperative effects of TAP block. We aimed to study the effects of TAP block in terms of cost-effectiveness and consumption of inhalation agents. MATERIAL AND METHODS: Forty patients undergoing laparoscopic cholecystectomy were enrolled in this study. Patients were randomly divided into 2 groups: Group 1 (n=20) patients received TAP block and Group 2 (n=20) patients did not receive TAP block. Standard anesthesia induction was used in all patients. For the maintenance of anesthesia, fractional inspired oxygen (FIO2) of 50% in air with desflurane was used with a fresh gas flow of 4 L/min. All patients were monitored with electrocardiography and for peripheral oxygen saturation (SpO2), end-tidal carbon dioxide (ET), heart rate (HR), noninvasive mean blood pressure (MBP), and bispectral index (BIS). Bilateral TAP blocks were performed under ultrasound guidance to Group 1 patients. The BIS value was maintained at between 40 and 50 during the surgery. The Dion formula was used to calculate consumption of desflurane for each patient. RESULTS: There was no difference between the groups with respect to demographic characteristics of the patients. Duration of anesthesia, surgery time, and dosage of fentanyl were similar in the 2 groups. However, the cost and consumption of desflurane was significantly lower in Group 1. CONCLUSIONS: Total anesthesia consumption was lower and the cost-effectiveness of anesthesia was better in TAP block patients with general anesthesia than in non-TAP block patients undergoing laparoscopic cholecystectomy.

Calculation of volatile anaesthetics consumption from agent concentration and fresh gas flow.

BACKGROUND: The assessment of volatile agents' consumption can be performed by weighing vapourisers before and after use. This method is technically demanding and unavailable for retrospective analysis of anaesthesia records. Therefore, a method based on calculations from fresh gas flow and agent concentration is presented here. METHODS: The presented calculation method herein enables a precise estimation of volatile agent consumption when average fresh gas flows and volatile agent concentrations are known. A pre-condition for these calculations is the knowledge of the vapour amount deriving from 1 ml fluid volatile agent. The necessary formulas for these calculations and an example for a sevoflurane anaesthesia are presented. RESULTS: The amount of volatile agent vapour deriving from 1 ml of fluid agent are for halothane 229 ml, isoflurane 195 ml, sevoflurane 184 m, and desflurane 210 ml. The constant for sevoflurane is used in a fictitious clinical case to exemplify the calculation of its consumption in daily routine resulting in a total expenditure of 23.6 ml liquid agent. CONCLUSIONS: By application of the presented specific volatile agent constants and equations, it becomes easy to calculate volatile agent consumption if the fresh gas flows and the resulting inhaled concentration of the volatile agent are known. By this method, it is possible to extract data about volatile agent consumption both ways: (1) retrospectively from sufficiently detailed and accurate anaesthesia recordings, as well as (2) by application of this method in a prospective setting. Therefore, this method is a valuable contribution to perform pharmacoeconomical surveys.

[Assessment of occupational exposure of medical personnel to inhalatory anesthetics in Poland]. / Ocena narazenia zawodowego personelu medycznego na anestetyki wziewne w Polsce.

BACKGROUND: Despite common use of inhalatory anesthetics, such as nitrous oxide (N2O), halothane, sevoflurane, and the like, occupational exposure to these substances in operating theatres was not monitored in Poland until 2006. The situation changed when maximum admissible concentration (MAC) values for anesthetics used in Poland were established in 2005 for N2O, and in 2007 for sevoflurane, desflurane and isoflurane. The aim of this work was to assess occupational exposure in operating rooms on the basis of reliable and uniform analytical procedures. MATERIAL AND METHODS: The method for the determination of all anesthetics used in Poland, i.e. nitrous oxide, sevoflurane, isoflurane, desflurane, and halothane, was developed and validated. The measurements were performed in 2006-2010 in 31 hospitals countrywide. The study covered 117 operating rooms; air samples were collected from the breathing zone of 146 anesthesiologists, and 154 nurses, mostly anaesthetic. The measurements were carried out during various surgical operations, mostly on adult patients but also in hospitals for children. RESULTS: Time weighted average concentrations of the anesthetics varied considerably, and the greatest differences were noted for N2O (0.1-1438.5 mg/m3); 40% of the results exceeded the MAC value. Only 3% of halothane, and 2% of sevoflurane concentrations exceeded the respective MAC values. CONCLUSIONS: Working in operating theatres is dangerous to the health of the operating staff. The coefficient of combined exposure to anesthesiologists under study exceeded the admissible value in 130 cases, which makes over 40% of the whole study population. Most of the excessive exposure values were noted for nitrous oxide.

A comparison of total intravenous anaesthesia using propofol with sevoflurane or desflurane in ambulatory surgery: systematic review and meta-analysis.

With the popularity of ambulatory surgery ever increasing, we carried out a systematic review and meta-analysis to determine whether the type of anaesthesia used had any bearing on patient outcomes. Total intravenous propofol anaesthesia was compared with two of the newer inhalational agents, sevoflurane and desflurane. In total, 18 trials were identified; only trials where nitrous oxide was administered to, or omitted from, both groups were included. A total of 1621 patients were randomly assigned to either propofol (685 patients) or inhalational anaesthesia (936 patients). If surgical causes of unplanned admissions were excluded, there was no difference in unplanned admission to hospital between propofol and inhalational anaesthesia (1.0% vs 2.9%, respectively; p = 0.13). The incidence of postoperative nausea and vomiting was lower with propofol than with inhalational agents (13.8% vs 29.2%, respectively; p < 0.001). However, no difference was noted in post-discharge nausea and vomiting (23.9% vs 20.8%, respectively; p = 0.26). Length of hospital stay was shorter with propofol, but the difference was only 14 min on average. The use of propofol was also more expensive, with a mean (95% CI) difference of £6.72 (£5.13-£8.31 (€8.16 (€6.23-€10.09); $11.29 ($8.62-$13.96))) per patient-anaesthetic episode (p < 0.001). Therefore, based on the published evidence to date, maintenance of anaesthesia using propofol appeared to have no bearing on the incidence of unplanned admission to hospital and was more expensive, but was associated with a decreased incidence of early postoperative nausea and vomiting compared with sevoflurane or desflurane in patients undergoing ambulatory surgery.

New generation pulse oximetry in the assessment of peripheral perfusion during general anaesthesia - a comparison between propofol and desflurane.

BACKGROUND: A pulse oximeter is a standard device for perioperative monitoring. It is well known that the early detection of tissue hypoxia is of great importance. It has been made easier due to a new generation pulse oximetry device from Masimo. This enables measurements of the peripheral perfusion index (PI) in real time. It has been found that volatile anaesthetics such as sevoflurane and desflurane increase the perfusion index. As we know, no data is available about perfusion index during propofol/remifentanil total intravenous anaesthesia. METHODS: ASA I and II class women scheduled for elective gynaecological surgery were eligible for the study. Patients were divided into two groups: group P receiving propofol/remifentanil intravenous anaesthesia and group D receiving desflurane/fentanyl general anaesthesia. PI was noted before anaesthesia, after remifentanil/fentanyl injection, after endotracheal intubation, at the beginning of surgery, during the procedure at ten minute intervals, at the end of the procedure, after awakening, after extubation and before discharge to the ward. RESULTS: Eighty-three patients were enrolled to the study. In both groups, PI increased significantly from the start to the end of surgery. There was a significant correlation between PI and end-tidal desflurane concentration (r = 0.807; P = 0.001). No correlation was found between propofol or remifentanil concentrations and PI. CONCLUSION: Both intravenous propofol/remifentanil and desflurane/fentanyl general anaesthesia increase peripheral perfusion. An increase in end-tidal desflurane concentration raises peripheral perfusion.

[Impact of the decrease of nitrous oxide use on the consumption of halogenated agents]. / Impact de la diminution d'utilisation du protoxyde d'azote sur la consommation d'agents halogénés.

OBJECTIVE: Nitrous oxide (N2O) toxicity and its impact on pollution lead to restrict its use. A decrease of N2O consumption should increase the hypnotic inhaled consumption. This monocentric study estimated consumptions and costs of halogenated agents (HA) and N2O over 5 years when the N2O consumption was reduced. STUDY DESIGN: Retrospective from a computerized database. PATIENTS: Between 2006 and 2010, 34,097 procedures were studied after two meetings exposing the risks of the N2O. METHODS: At the end of anesthesia, consumptions of hypnotic agents (millilitres transmitted by the injectors and the blender) were archived in the database. The annual consumption of agents was obtained by adding the individual consumptions, then divided by the annual number of cases. The costs were given by the hospital pharmacy from invoices. RESULTS: N2O consumption per anesthesia constantly decreased during the study, from 75.1L by act to 22.7L. The sum of the annual consumptions of N2O and air did not change suggesting that total fresh gas flow remained stable. Between 2006 and 2010, the sevoflurane consumption by act increased by 25%, from 16.5 to 20.6mL, and desflurane consumption by 37%, from 46.1 to 63.1mL by patient. The costs of the administration of hypnotic agents remained stable. CONCLUSION: N2O consumption decrease had an impact on the consumption of HA. The cost reduction of the N2O was counterbalanced by the increase of halogenated vapor cost. The profit of the ecological impact of the reduction in N2O use could be quantified.

Effects of anesthetic isoflurane and desflurane on human cerebrospinal fluid Aß and τ level.

BACKGROUND: Accumulation of ß-amyloid protein (Aß) and tau protein is the main feature of Alzheimer disease neuropathogenesis. Anesthetic isoflurane, but not desflurane, may increase Aß levels in vitro and in animals. Therefore, we set out to determine the effects of isoflurane and desflurane on cerebrospinal fluid (CSF) levels of Aß and tau in humans. METHODS: The participants were assigned into spinal anesthesia (N=35), spinal plus desflurane anesthesia (N=33), or spinal plus isoflurane anesthesia (N=38) group by randomization using computer-generated lists. Pre- and postoperative human CSF samples were obtained through an inserted spinal catheter. The levels of Aß (Aß40 and Aß42) and total tau in the CSF were determined. RESULTS: Here, we show that isoflurane, but not desflurane, was associated with an increase in human CSF Aß40 levels (from 10.90 to 12.41 ng/ml) 24 h after the surgery under anesthesia compared to spinal anesthesia (from 11.59 to 11.08 ng/ml), P=0.022. Desflurane, but not isoflurane, was associated with a decrease in Aß42 levels 2 h after the surgery under anesthesia (from 0.39 to 0.35 ng/ml) compared to spinal anesthesia (from 0.43 to 0.44 ng/ml), P=0.006. Isoflurane and desflurane did not significantly affect the tau levels in human CSF. CONCLUSIONS: These studies have established a system to study the effects of anesthetics on human biomarkers associated with Alzheimer disease and cognitive dysfunction. These findings have suggested that isoflurane and desflurane may have different effects on human CSF Aß levels.

Financial and environmental costs of manual versus automated control of end-tidal gas concentrations.

Emerging technologies that reduce the economic and environmental costs of anaesthesia have had limited assessment. We hypothesised that automated control of end-tidal gases, a new feature in anaesthesia machines, will consistently reduce volatile agent consumption cost and greenhouse gas emissions. As part of the planned replacement of anaesthesia machines in a tertiary hospital, we performed a prospective before and after study comparing the cost and greenhouse gas emissions of isoflurane, sevoflurane and desflurane when using manual versus automated control of end-tidal gases. We analysed 3675 general anaesthesia cases with inhalational agents: 1865 using manual control and 1810 using automated control. Volatile agent cost was $18.87/hour using manual control and $13.82/hour using automated control: mean decrease $5.05/hour (95% confidence interval: $0.88-9.22/hour, P=0.0243). The 100-year global warming potential decreased from 23.2 kg/hour of carbon dioxide equivalents to 13.0 kg/hour: mean decrease 10.2 kg/hour (95% confidence interval: 2.7-17.7 kg/hour, P=0.0179). Automated control reduced costs by 27%. Greenhouse gas emissions decreased by 44%, a greater than expected decrease facilitated by a proportional reduction in desflurane use. Automated control of end-tidal gases increases participation in low flow anaesthesia with economic and environmental benefits.

Pain monitoring in anesthetized children: first assessment of skin conductance and analgesia-nociception index at different infusion rates of remifentanil.

BACKGROUND: Analgesia and nociception can not be specifically monitored during general anesthesia. Movement of the patient or hemodynamic variations are usually considered as symptoms of insufficient analgesia. The measure of skin conductance (SC) allows an assessment of peripheral sympathetic activity. The analgesia-nociception index (ANI) provides an evaluation of the parasympathetic activity based on heart rate variability. These two non-invasive monitors might allow a better assessment of perioperative nociception. OBJECTIVES: Describe the profiles of SC and ANI after a standardized nociceptive stimulation, in anesthetized children, at different infusion rates of remifentanil. MATERIALS/METHODS: For this pilot study, 12 children (8.4 ± 5 years) scheduled for middle-ear surgery were anesthetized with desflurane to maintain a bispectral index at 50. Remifentanil was used for analgesia, at an initial infusion rate of 0.2 µg·kg(-1) ·min(-1) . Remifentanil infusion rate was then decreased: Five steady-state periods of 10 min were obtained at 0.2, 0.16, 0.12, 0.08, and 0.04 µg·kg(-1) ·min(-1) . At the end of each period, a standardized tetanic stimulation was applied to the patient. Variations in heart rate, blood pressure, SC, and ANI were recorded before and after each stimulation. RESULTS: After the stimulation, ANI was significantly decreased compared with prestimulation values for all remifentanil infusion rates. This decrease was greater at 0.04 µg·kg(-1) ·min(-1) than at the other infusion rates. SC, heart rate, and blood pressure were not modified by the stimulations, whatever the dose of remifentanil. CONCLUSION: ANI might provide a more sensitive assessment of nociception in anesthetized children than hemodynamic parameters or skin conductance.

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.

Life cycle greenhouse gas emissions of anesthetic drugs.

BACKGROUND: Anesthesiologists must consider the entire life cycle of drugs in order to include environmental impacts into clinical decisions. In the present study we used life cycle assessment to examine the climate change impacts of 5 anesthetic drugs: sevoflurane, desflurane, isoflurane, nitrous oxide, and propofol. METHODS: A full cradle-to-grave approach was used, encompassing resource extraction, drug manufacturing, transport to health care facilities, drug delivery to the patient, and disposal or emission to the environment. At each stage of the life cycle, energy, material inputs, and emissions were considered, as well as use-specific impacts of each drug. The 4 inhalation anesthetics are greenhouse gases (GHGs), and so life cycle GHG emissions include waste anesthetic gases vented to the atmosphere and emissions (largely carbon dioxide) that arise from other life cycle stages. RESULTS: Desflurane accounts for the largest life cycle GHG impact among the anesthetic drugs considered here: 15 times that of isoflurane and 20 times that of sevoflurane on a per MAC-hour basis when administered in an O(2)/air admixture. GHG emissions increase significantly for all drugs when administered in an N(2)O/O(2) admixture. For all of the inhalation anesthetics, GHG impacts are dominated by uncontrolled emissions of waste anesthetic gases. GHG impacts of propofol are comparatively quite small, nearly 4 orders of magnitude lower than those of desflurane or nitrous oxide. Unlike the inhaled drugs, the GHG impacts of propofol primarily stem from the electricity required for the syringe pump and not from drug production or direct release to the environment. DISCUSSION: Our results reiterate previous published data on the GHG effects of these inhaled drugs, while providing a life cycle context. There are several practical environmental impact mitigation strategies. Desflurane and nitrous oxide should be restricted to cases where they may reduce morbidity and mortality over alternative drugs. Clinicians should avoid unnecessarily high fresh gas flow rates for all inhaled drugs. There are waste anesthetic gas capturing systems, and even in advance of reprocessed gas applications, strong consideration should be given to their use. From our results it appears likely that techniques other than inhalation anesthetics, such as total i.v. anesthesia, neuraxial, or peripheral nerve blocks, would be least harmful to the environment.

Desflurane: a clinical update of a third-generation inhaled anaesthetic.

Available volatile anaesthetics are safe and efficacious; however, their varying pharmacology provides small but potentially clinically important differences. Desflurane is one of the third-generation inhaled anaesthetics. It is the halogenated inhaled anaesthetic with the lowest blood and tissue solubilities, which promotes its rapid equilibration and its rapid elimination following cessation of administration at the end of anaesthesia. The low fat solubility of desflurane provides pharmacological benefits, especially in overweight patients and in longer procedures by reducing slow compartment accumulation. A decade of clinical use has provided evidence for desflurane's safe and efficacious use as a general anaesthetic. Its benefits include rapid and predictable emergence, and early recovery. In addition, the use of desflurane promotes early and predictable extubation, and the ability to rapidly transfer patients from the operating theatre to the recovery area, which has a positive impact on patient turnover. Desflurane also increases the likelihood of patients, including obese patients, recovering their protective airway reflexes and awakening to a degree sufficient to minimise the stay in the high dependency recovery area. The potential impact of the rapid early recovery from desflurane anaesthesia on intermediate and late recovery and resumption of activities of daily living requires further study.