Different ethanol exposure durations affect cytochrome P450 2E1-mediated sevoflurane metabolism in rat liver.

BACKGROUND: Chronic alcohol users often exhibit an increased minimum alveolar concentration (MAC) of sevoflurane, yet the specific mechanism remains unclear. It has been reported that ethanol exposure can upregulate the protein expression and enzyme activity of cytochrome P450 2E1 (CYP2E1). CYP2E1 is a key enzyme that converts 2-5% of sevoflurane into equimolar amounts of hexafluoroisopropanol (HFIP) and F-. This study aims to explore whether ethanol exposure could alter sevoflurane metabolism through CYP2E1 modulation, potentially explaining the increased MAC observed in alcohol users. METHODS: Eighty adult male Sprague-Dawley (SD) rats were randomly divided into two groups and received either 50% ethanol (dose: 3 g/kg) or 0.9% saline twice daily by gavage. After 1, 2, 3, and 4 weeks of gavage, ten rats were randomly selected from each group to undergo 1-hour anesthesia with 2.3% sevoflurane. Blood samples were collected after anesthesia to measure the concentration of free HFIP using gas chromatography. Additionally, the left lobe tissue of the liver was collected for the analysis of CYP2E1 protein expression by Western blot and CYP2E1 enzyme activity by colorimetric assay. Correlations between these parameters were analyzed using Pearson's correlation. RESULTS: In the ethanol group, CYP2E1 expression, activity, and the concentration of free HFIP were significantly higher at all time points compared to the control group (P < 0.05), except for protein expression in the first week (P > 0.05). Within-group comparisons indicated no significant changes in any of the parameters for the control group (P > 0.05). In the ethanol group, there was no difference in free HFIP concentration between the first and second weeks (P > 0.05), but a significant increase was observed in the third and fourth weeks (P < 0.01); protein expression and enzyme activity significantly varied over time, especially showing a notable increase from the first to the third and fourth weeks (P < 0.05). Correlation analysis revealed strong positive correlations between free HFIP concentration and CYP2E1 activity (r = 0.7898), free HFIP concentration and CYP2E1 expression (r = 0.8418), and CYP2E1 activity and expression (r = 0.8740), all with P < 0.001. CONCLUSIONS: Ethanol exposure increased both the expression and enzymatic activity of CYP2E1, consequently enhancing the metabolism of sevoflurane.

Propofol total intravenous anesthesia vs. sevoflurane inhalation anesthesia: Effects on post­operative cognitive dysfunction and inflammation in geriatric patients undergoing laparoscopic surgery.

Propofol total intravenous anesthesia (TIVA) or sevoflurane inhalation anesthesia (IA) affects post-operative cognitive dysfunction in geriatric patients undergoing laparoscopic surgery; however, relevant real-world clinical evidence on the matter is limited. The present study aimed to compare the effects of propofol TIVA and sevoflurane IA on post-operative cognitive dysfunction in the aforementioned type of patients. The present prospective study enrolled 197 geriatric patients undergoing laparoscopic surgery. Patients were assigned to the propofol TIVA group (n=97) and sevoflurane IA group (n=100) according to the actual anesthesia regimens. The mini-mental state examination (MMSE) score was assessed before surgery and on day (D)1, D3 and D7 following surgery in both groups. The MMSE score on D1 was higher in the TIVA group compared with the IA group (P=0.006). The change in the MMSE scores from before surgery to D1 (P<0.001), D3 (P=0.011) and D7 (P=0.003) was smaller in the TIVA group vs. the IA group. Multivariate linear regression analyses suggested that the anesthesia method of TIVA (vs. IA) was independently related to the increased MMSE score on D1 (b=0.803; P=0.001) and D7 (b=0.472; P=0.025). The levels of interleukin (IL)-17A, IL-6 and tumor necrosis factor-α on D1, D3 and D7 exhibited a slightly decreasing trend in the TIVA group vs. the IA group, although the difference was not statistically significant (all P>0.05). Notably, the levels of IL-17A before surgery (P=0.015), on D3 (P=0.016) and D7 (P=0.002), as well as those of IL-6 on D1 (P=0.027), were negatively associated with the MMSE score at the corresponding time points. Overall, the present study demonstrates that propofol TIVA ameliorates post-operative cognitive dysfunction on D1 compared with sevoflurane IA and exerts a potentially suppressive effect on inflammation in geriatric patients undergoing laparoscopic surgery.

Effect of a non-reactive absorbent with or without environmentally oriented electronic feedback on anesthesia provider's fresh gas flow rates: A greening initiative.

STUDY OBJECTIVE: To examine the effects of a non-reactive carbon dioxide absorbent (AMSORB® Plus) versus a traditional carbon dioxide absorbent (Medisorb™) on the FGF used by anesthesia providers and an electronic educational feedback intervention using Carestation™ Insights (GE HealthCare) on provider-specific change in FGF. DESIGN: Prospective, single-center cohort study set in a greening initiative. SETTING: Operating room. PARTICIPANTS: 157 anesthesia providers (i.e., anesthesiology trainees, certified registered nurse anesthetists, and solo anesthesiologists). INTERVENTIONS: Intervention #1 was the introduction of AMSORB® Plus into 8 Aisys CS2, Carestation™ Insights-enabled anesthesia machines (GE HealthCare) at the study site. At the end of week 6, anesthesia providers were educated and given an environmentally oriented electronic feedback strategy for the next 12 weeks of the study (Intervention #2) using Carestation™ Insights data. MEASUREMENTS: The dual primary outcomes were the difference in average daily FGF during maintenance anesthesia between machines assigned to AMSORB® Plus versus Medisorb™ and the provider-specific change in average fresh gas flows after 12 weeks of feedback and education compared to the historical data. MAIN RESULTS: Over the 18-week period, there were 1577 inhaled anesthetics performed in the 8 operating rooms (528 for intervention 1, 1049 for intervention 2). There were 1001 provider days using Aisys CS2 machines and 7452 provider days of historical data from the preceding year. Overall, AMSORB® Plus was not associated with significantly less FGF (mean - 80 ml/min, 97.5% confidence interval - 206 to 46, P = .15). The environmentally oriented electronic feedback intervention was not associated with a significant decrease in provider-specific mean FGF (-112 ml/min, 97.5% confidence interval - 244 to 21, P = .059). CONCLUSIONS: This study showed that introducing a non-reactive absorbent did not significantly alter FGF. Using environmentally oriented electronic feedback relying on data analytics did not result in significantly reduced provider-specific FGF.

Carbon Footprint of Total Intravenous and Inhalation Anesthesia in the Transcatheter Aortic Valve Replacement Procedure.

OBJECTIVES: To quantify and compare the emissions for deep sedation with total intravenous anesthesia (TIVA) and general anesthesia with inhaled agents during the transcatheter aortic valve replacement procedure. DESIGN: A retrospective study. SETTING: A tertiary hospital in Boston, Massachusetts. PARTICIPANTS: The anesthesia records of 604 consecutive patients who underwent the transcatheter aortic valve replacement procedure between January 1, 2018, and March 31, 2022, were reviewed and analyzed. INTERVENTIONS: Data were examined and compared in the following 2 groups: general anesthesia with inhaled agents and deep sedation with TIVA. MEASUREMENTS AND MAIN RESULTS: The gases, drugs, airway management devices, and anesthesia machine electricity were collected and converted into carbon dioxide emissions (CO2e). The carbon emissions of intravenous medications were converted with the CO2e data for anesthetic pharmaceuticals from the Parvatker et al. study. For inhaled agents, inhaled anesthetics and oxygen/air flow rate were collected at 15-minute intervals and calculated using the anesthetic gases calculator provided by the Association of Anesthetists. The airway management devices were converted based on life-cycle assessments. The electricity consumed by the anesthesia machine during general anesthesia was estimated from the manufacturer's data (Dräger, GE) and local Energy Information Administration data. The data were analyzed in the chi-squared test or Wilcoxon rank-sum test. There were no significant differences in the patients' demographic characteristics, such as age, sex, weight, height, and body mass index. The patients who received general anesthesia with inhaled agents had statistically higher total CO2e per case than deep sedation with TIVA (16.188 v 1.518 kg CO2e; p < 0.001), primarily due to the inhaled agents and secondarily to airway management devices. For deep sedation with TIVA, the major contributors were intravenous medications (71.02%) and airway management devices (16.58%). A subgroup study of patients who received sevoflurane only showed the same trend with less variation. CONCLUSIONS: The patients who received volatile anesthesia were found to have a higher CO2e per case. This difference remained after a subgroup analysis evaluating those patients only receiving sevoflurane and after accounting for the differences in the duration of anesthesia. Data from this study and others should be collectively considered as the healthcare profession aims to provide the best care possible for their patients while limiting the harm caused to the environment.

Minimum anesthetic concentration of isoflurane and sevoflurane and cardiorespiratory effects of varying inspired oxygen fractions in Magellanic penguins (Spheniscus magellanicus).

The aim of this study was to determine the minimum anesthetic concentration of isoflurane (MACISO) and sevoflurane (MACSEVO) and evaluate the cardiorespiratory changes induced by varying fractions of inspired oxygen (FiO2) in Magellanic penguins (Spheniscus magellanicus). Twenty adult penguins (3.53 ± 0.44 kg) of undetermined sex were used. Both MACISO (n = 9) and MACSEVO (n = 13) were established using an up-and-down design. Next, twelve mechanically ventilated penguins were maintained at 1 MACISO or 1 MACSEVO (n = 6 per group) with the FiO2 initially set at 1.0. Three FiO2 values (0.6, 0.4 and 0.2) were then held constant during anesthesia for 20 minutes each. Arterial blood samples were collected for gas analysis after the 20-minute period for each FiO2. Mean ± SD MACISO was 1.93 ± 0.10% and MACSEVO was 3.53 ± 0.13%. Other than heart rate at 0.6 FiO2 (86 ± 11 beats/minute in MACISO and 132 ± 37 beats/minute in MACSEVO; p = 0.041), no significant cardiorespiratory differences were detected between groups. In both groups, decreasing the FiO2 produced increased pH values and reduced partial pressures of carbon dioxide and bicarbonate. Partial pressures of oxygen (PaO2) gradually lowered from 1.0 FiO2 through 0.2 FiO2, though hypoxemia (PaO2 < 80 mmHg) occurred only with the latter FiO2. The MACISO and the MACSEVO for the Magellanic penguin fell within the upper range of reported avian MAC estimates. To prevent hypoxemia in healthy, mechanically ventilated, either isoflurane- or sevoflurane-anesthetized Magellanic penguins, a minimum FiO2 of 0.4 should be used.

Effects of anesthesia on long-term survival in cancer surgery: A systematic review and meta-analysis.

Backgrounds: The association between anesthesia and long-term oncological outcome after cancer surgery remains controversial. This study aimed to investigate the effect of propofol-based anesthesia and inhalation anesthesia on long-term survival in cancer surgery. Methods: A comprehensive literature search was performed in PubMed, Medline, Embase, and the Cochrane Library until November 15, 2023. The outcomes included overall survival (OS) and recurrence-free survival (RFS). The hazard ratio (HR) and 95 % confidence interval (CI) were calculated with a random-effects model. Results: We included forty-two retrospective cohort studies and two randomized controlled trials (RCTs) with 686,923 patients. Propofol-based anesthesia was associated with improved OS (HR = 0.82, 95 % CI:0.76-0.88, P < 0.00001) and RFS (HR = 0.80, 95 % CI:0.73-0.88, P < 0.00001) than inhalation anesthesia after cancer surgery. However, these positive results were only observed in single-center studies (OS: HR = 0.76, 95 % CI:0.68-0.84, P < 0.00001; RFS: HR = 0.76, 95 % CI:0.66-0.87, P < 0.0001), but not in multicenter studies (OS: HR = 0.98, 95 % CI:0.94-1.03, P = 0.51; RFS: HR = 0.95, 95 % CI:0.87-1.04, P = 0.26). The subgroup analysis revealed that propofol-based anesthesia provided OS and RFS advantages in hepatobiliary cancer (OS: HR = 0.58, 95 % CI:0.40-0.86, P = 0.005; RFS: HR = 0.62, 95 % CI:0.44-0.86, P = 0.005), gynecological cancer (OS: HR = 0.52, 95 % CI:0.33-0.81, P = 0.004; RFS: HR = 0.51, 95 % CI:0.36-0.72, P = 0.0001), and osteosarcoma (OS: HR = 0.30, 95 % CI:0.11-0.81, P = 0.02; RFS: HR = 0.32, 95 % CI:0.14-0.75, P = 0.008) surgeries. Conclusion: Propofol-based anesthesia may be associated with improved OS and RFS than inhalation anesthesia in some cancer surgeries. Considering the inherent weaknesses of retrospective designs and the strong publication bias, our findings should be interpreted with caution. Well-designed multicenter RCTs are still urgent to further confirm these findings.

Comparison of the Effects of Desflurane and Sevoflurane on Variations in Salivary Melatonin and Sleep Disturbance After Total Knee Arthroplasty: A Single-center, Prospective, Randomized, Controlled, Open-label Study.

PURPOSE: Anesthesia has been shown to disrupt the circadian rhythm. Recovery of the circadian rhythm after general anesthesia might help alleviate symptoms of insomnia and postoperative delirium. We hypothesized that recovery of the circadian rhythm is faster after total knee arthroplasty (TKA) with desflurane than with sevoflurane. This study compared the influence of sevoflurane versus desflurane anesthesia on the postoperative circadian rhythm of melatonin in adults undergoing TKA. DESIGN: Single-center, prospective, randomized, controlled, open-label study. METHODS: This study involved adult patients undergoing TKA at a university hospital in Japan from May 1, 2018 to December 31, 2019. The primary outcome of the study was the comparison of the effect of sevoflurane and desflurane on the circadian rhythm of salivary melatonin for 3 days postoperatively. The secondary outcomes were postoperative fatigue and sleep quality for 3 days postoperatively. FINDINGS: Twenty-eight patients (American Society of Anesthesiologists physical status of I or II) were scheduled for TKA and randomized to receive sevoflurane (n = 14) or desflurane (n = 14) anesthesia. There was no significant difference in the melatonin concentration between the sevoflurane and desflurane groups. The salivary melatonin concentration after sevoflurane or desflurane anesthesia was significantly higher at 9:00 p.m. on a postoperative day (POD)0 and POD1 than on POD3 (P < .05). Patients in the desflurane group had significantly greater fatigue than those in the sevoflurane group at 7:00 a.m. and 12:00 p.m. on POD3 (P < .05). Patients in the sevoflurane group had a deeper sleep than those in the desflurane group on POD0 (P < .05). In the sevoflurane group, the sleep time during the night of POD2 was longer than that on POD0 (6.1 vs 4.2 hours, P < .05). CONCLUSIONS: Under the current study conditions, desflurane was equivalent to sevoflurane in terms of the postoperative salivary melatonin concentration and sleep disturbance after TKA but not in terms of recovering the postoperative circadian rhythm.

Randomized controlled trial of the effect of general anesthetics on postoperative recovery after minimally invasive nephrectomy.

BACKGROUND: General anesthetic techniques can affect postoperative recovery. We compared the effect of propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia on postoperative recovery. METHODS: In this randomized trial, 150 patients undergoing robot-assisted or laparoscopic nephrectomy for renal cancer were randomly allocated to either the TIVA or desflurane anesthesia (DES) group. Postoperative recovery was evaluated using the Korean version of the Quality of Recovery-15 questionnaire (QoR-15K) at 24 h, 48 h, and 72 h postoperatively. A generalized estimating equation (GEE) was performed to analyze longitudinal QoR-15K data. Fentanyl consumption, pain severity, postoperative nausea and vomiting, and quality of life three weeks after discharge were also compared. RESULTS: Data were analyzed for 70 patients in each group. The TIVA group showed significantly higher QoR-15K scores at 24 and 48 h postoperatively (24 h: DES, 96 [77, 109] vs. TIVA, 104 [82, 117], median difference 8 [95% CI: 1, 15], P = 0.029; 48 h: 110 [95, 128] vs. 125 [109, 130], median difference 8 [95% CI: 1, 15], P = 0.022), however not at 72 h (P = 0.400). The GEE revealed significant effects of group (adjusted mean difference 6.2, 95% CI: 0.39, 12.1, P = 0.037) and time (P < 0.001) on postoperative QoR-15K scores without group-time interaction (P = 0.051). However, there were no significant differences in other outcomes, except for fentanyl consumption, within the first 24 h postoperatively. CONCLUSIONS: Propofol-based TIVA showed only a transient improvement in postoperative recovery than desflurane anesthesia, without significant differences in other outcomes.

Effects of combinedintravenous and inhalation anesthesia on immune function and cognitive function in postoperative cirrhotic patients with a background in athletics and fitness

Objective: To evaluate the effects of combined intravenous and inhalation anesthesia on postoperative immune and cognitive function in cirrhotic patients, particularly those with a background in athletics and fitness. Methods: A systematic literature search was conducted in the Cochrane Library, Web of Science, PubMed, ProQuest, and Chinese biomedical literature databases (Wanfang, Weipu, CNKI) for controlled trials assessing combined intravenous and inhalation anesthesia in cirrhotic patients, with an emphasis on those maintaining an athletic or fitness-oriented lifestyle. The literature was analyzed using RevMan 5.3 software, focusing on exploring the heterogeneity of the studies. Results: Nine research papers were included in the meta-analysis, encompassing a total of 775 subjects, including 382 in the control group and 393 in the experimental group. Among these, a significant portion of the subjects were identified as being involved in regular athletic or fitness activities. Eight papers were prospective studies, and one was retrospective. The meta[1]analysis revealed that combined intravenous and inhalation anesthesia significantly increased CD3+, CD4+, and CD8+ levels, and improved the CD4+/CD8+ ratio, demonstrating enhanced immune function. Additionally, cognitive function improvements were noted [OR: 1.45, 95% CI (1.03, 1.87), P<0.00001]. There were also significant improvements in liver function markers ALT and ALB. Funnel plots indicated no publication bias (AU)

The effect of intravenous and inhalation anesthesia in general on the cognition of elderly patients undergoing non-cardiac surgery: a systematic review and meta-analysis.

Background: Postoperative cognitive dysfunction (POCD) is a postoperative complication that often occurs in the elderly. This systematic review and meta-analysis aimed to compare intravenous anesthetics (propofol) with inhalation anesthetics (sevoflurane) regarding the occurrence of POCD in the elderly who underwent non-cardiac surgery. Methods: The investigators searched for published articles from the PubMed, Embase, Web of Science, Scopus, Cochrane, and Clinicalkey databases. Clinical studies comparing the incidence of POCD in elderly patients undergoing intravenous or inhalation anesthesia in general were selected. Primary outcomes included the occurrence of POCD at 1, 3, and 7 days. The secondary outcomes were the patient's plasma S-100ß protein levels (pg*mL-1) and delayed neurocognitive recovery incidence 5-7 days after surgery. Results: Fifteen studies including 3,817 patients were enrolled in the systematic review. Ten studies involving 1,829 patients were enrolled in the meta-analysis. The results demonstrate that there was no difference between the intravenous and inhalation groups in the incidence of POCD within 1-7 days (95% CI 0.73-1.26, p = 0.77) and the occurrence of delayed neurocognitive recovery 5-7 days after surgery (95% CI -353.15 to -295.44, p = 0.28). Plasma S-100ß protein levels in the intravenous anesthesia group were lower than those in the inhalation group (95% CI 0.48-1.24, p < 0.001). Conclusion: For elderly patients undergoing non-cardiac surgery, inhalation anesthesia was comparable to intravenous anesthesia in terms of the occurrence of short-term POCD. Inhalation anesthesia may cause greater damage to the nervous system, with delayed recovery of cognitive function after 5-7 days showing no difference. Systematic review: identifier (CRD42021251317).

Successful anesthesia management with inhalation anesthesia in Rosai-Dorfman disease: a case report.

Rosai-Dorfman disease (RDD) is a rare, benign, non-Langerhans cell histiocytic proliferative disease. RDD with central nervous system involvement is extremely rare. Surgical excision is generally regarded as the appropriate treatment of choice for this disease, especially when the lesion causes neurological compression. RDD can be accompanied by systemic symptoms, such as malaise, fever, weight change, leukocytosis, anemia, and hormonal disturbance, which may be challenging during general management. Little is known regarding peri-anesthesia management of this rare disease. We report a case of a patient in his 20s who had recurrent RDD and had general anesthesia with perioperative management. He was obese and hepatic insufficiency. This case report adds to the literature regarding the perioperative anesthetic management of RDD with central nervous system involvement.

Impact of total intravenous anesthesia and total inhalation anesthesia as the anesthesia maintenance approaches on blood glucose level and postoperative complications in patients with type 2 diabetes mellitus: a double-blind, randomized controlled trial.

BACKGROUND: Diabetes mellitus is a prevalent metabolic disease in the world. Previous studies have shown that anesthetics can affect perioperative blood glucose levels which related to adverse clinical outcomes. Few studies have explored the choice of general anesthetic protocol on perioperative glucose metabolism in diabetes patients. We aimed to compare total intravenous anesthesia (TIVA) with total inhalation anesthesia (TIHA) on blood glucose level and complications in type 2 diabetic patients undergoing general surgery. METHODS: In this double-blind controlled trial, 116 type 2 diabetic patients scheduled for general surgery were randomly assigned to either the TIVA group or TIHA group (n = 56 and n = 60, respectively). The blood glucose level at different time points were measured and analyzed by the repeated-measures analysis of variance. The serum insulin and cortisol levels were measured and analyzed with t-test. The incidence of complications was followed up and analyzed with chi-square test or Fisher's exact test as appropriate. The risk factors for complications were analyzed using the logistic stepwise regression. RESULTS: The blood glucose levels were higher in TIHA group than that in TIVA group at the time points of extubation, 1 and 2 h after the operation, 1 and 2 days after the operation, and were significantly higher at 1 day after the operation (10.4 ± 2.8 vs. 8.1 ± 2.1 mmol/L; P < 0.01). The postoperative insulin level was higher in TIVA group than that in TIHA group (8.9 ± 2.9 vs. 7.6 ± 2.4 IU/mL; P = 0.011). The postoperative cortisol level was higher in TIHA group than that in TIVA group (15.3 ± 4.8 vs. 12.2 ± 8.9 ug/dL ; P = 0.031). No significant difference regarding the incidence of complications between the two groups was found based on the current samples. Blood glucose level on postoperative day 1 was a risk factor for postoperative complications (OR: 1.779, 95%CI: 1.009 ~ 3.138). CONCLUSIONS: TIVA has less impact on perioperative blood glucose level and a better inhibition of cortisol release in type 2 diabetic patients compared to TIHA. A future large trial may be conducted to find the difference of complications between the two groups. TRIAL REGISTRATION: The protocol registered on the Chinese Clinical Trials Registry on 20/01/2020 (ChiCTR2000029247).

Comparative analysis of anesthesia and clinical efficacy of inhalation anesthesia and intravenous anesthesia in Trigeminal Nerve Balloon Avulsion.

Objective: To observe the anesthesia and clinical efficacy of inhalation anesthesia and intravenous anesthesia in patients with trigeminal neuralgia undergoing surgery. Methods: This is a retrospective study. Eighty patients with trigeminal neuralgia admitted to the Affiliated Hospital of Beihua University from July 2018 to July 2021 were selected and divided into two groups according to different anesthesia methods: inhalation group and intravenous group, with 40 cases in each group. Patients in the inhalation group were given inhalation anesthesia with sevoflurane, while those in the intravenous group were given intravenous anesthesia. Hemodynamics, intubation and extubation time, postoperative consciousness recovery, adverse reactions and clinical effects of surgery were compared between the two groups during anesthesia. Results: During the induction of anesthesia, after induction and after surgery, the levels of hemodynamic parameters in the two groups increased compared with those before induction of anesthesia, and the increase in the inhalation group was smaller (P<0.05). Patients in the inhalation group had a long time from anesthesia to endotracheal intubation but had a short time from completion of surgery to intubation, which was statistically significant compared with the intravenous group (P<0.05). Compared with the intravenous group, the postoperative consciousness recovery time of the inhalation group was significantly shorter and the incidence of adverse reactions was significantly lower (P<0.05). Conclusion: Inhalation anesthesia with sevoflurane is more effective than intravenous anesthesia in trigeminal neuralgia patients treated with trigeminal nerve balloon avulsion, boasting satisfactory safety, less impact on hemodynamics, and shorter recovery time of consciousness.

Determination of the minimum alveolar concentration of sevoflurane in Holstein steers.

OBJECTIVE: To determine the minimum alveolar concentration (MAC) of sevoflurane in Holstein steers using electric stimulation. STUDY DESIGN: Prospective experimental study. ANIMALS: A total of 15 Holstein steers aged 7.3 ± 1.2 months and weighing 121 ± 25 kg. METHODS: Animals were anesthetized with sevoflurane at 8% in oxygen at 5 L minute-1 via facemask and were intubated with an orotracheal tube of a compatible size. After 15 minutes of stabilization of the initial expired concentration of sevoflurane (Fe'Sevo) at 2.6%, electrical stimulation on the thoracic limb was initiated with a sequence of 2 × 10 ms followed by 2 × 3 second electrical currents of 50 V and 50 Hz, 5 seconds apart. Following each stimulus with a negative response, the Fe'Sevo was decreased by 0.2% and a 15 minute interval was awaited before the next stimulus. The procedure was repeated until the first Fe'Sevo value with a positive motor response was obtained. The Fe'Sevo was then increased by 0.1%, followed by a new stimulus, until a negative response was obtained. The value of MAC was calculated as the arithmetic mean between the lowest Fe'Sevo associated with a negative motor response and the highest Fe'Sevo associated with a positive response. RESULTS: The mean MAC for the 15 steers was 2.0 ± 0.3%, which corresponds to 2.1 ± 0.3% at sea level. CONCLUSIONS: Based on the proposed methodology, the MAC of sevoflurane for healthy Holstein steers is 2.1 ± 0.3% at sea level. CLINICAL RELEVANCE: This Fe'Sevo value can be used to guide depth of anesthesia in steers weighing approximately 120 kg in clinical practice.

Challenging case of severe acute asthma in a mechanically ventilated patient managed with sevoflurane.

Acute severe bronchial asthma is a chronic inflammatory disease characterized by hyperresponsiveness of the airways leading to bronchoconstriction. We present a case of refractory life-threatening bronchial asthma that was managed with sevoflurane gas along with the standard treatment and achieved stability and clinical improvement through its bronchodilator and anesthetic effect.

Accidental intrathecal injection of tranexamic acid: a case report.

BACKGROUND: Tranexamic acid is a well-known antifibrinolytic medication frequently prescribed to individuals with bleeding disorders. Following accidental intrathecal injection of tranexamic acid, major morbidities and fatalities have been documented. The aim of this case report is to present a novel method for management of intrathecal injection of tranexamic acid. CASE PRESENTATION: In this case report, a 400 mg intrathecal injection of tranexamic acid resulted in significant back and gluteal pain, myoclonus of the lower limbs, agitation, and widespread convulsions in a 31-year-old Egyptian male with history of left arm and right leg fracture. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 µg) was delivered with no response in seizure termination. A 1000 mg phenytoin intravenous infusion and subsequently, induction of general anesthesia was performed by thiopental sodium (250 mg) and atracurium (50 mg) infusion, and the trachea of the patient was intubated. Maintenance of anesthesia was achieved by isoflurane 1.2 minimum alveolar concentration and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. The patient developed focal seizures in the hand and leg, so cerebrospinal fluid lavage was done by inserting two spinal 22-gauge Quincke tip needles, one on level L2-L3 (drainage) and the other on L4-L5. Intrathecal normal saline infusion (150 ml) was done over an hour by passive flow. After cerebrospinal fluid lavage and the patient's stabilization was obtained, he was transferred to the intensive care unit. CONCLUSIONS: Early and continuous intrathecal lavage with normal saline, with the airway, breathing, and circulation protocol is highly recommended to decrease morbidity and mortality. The selection of the inhalational drug as a sedative and for brain protection in the intensive care unit provided possible benefits in management of this event with medication errors.

Association of Volatile Versus Intravenous Anesthesia With Prognosis After Nephrectomy for Renal Cell Carcinoma.

BACKGROUND/AIM: A recent preclinical study reported that renal cell carcinoma was more susceptible to sevoflurane-mediated metastatic potentiation, compared to non-small cell lung cancer, suggesting that the effect of anesthetic agents on the metastatic potential varies according to cancer type. Based on this report, we conducted a retrospective cohort study to compare recurrence-free survival after nephrectomy, between renal cell carcinoma patients receiving volatile anesthesia and those receiving intravenous anesthesia. PATIENTS AND METHODS: We reviewed the electronic medical records of patients who underwent partial or radical nephrectomy for renal cell carcinoma at the Seoul National University Hospital. Patients were divided into two groups according to whether volatile or intravenous anesthesia was used for nephrectomy. A total of 651 patients (582 in the volatile and 69 in the intravenous group) were enrolled in the study. Recurrence-free survival after nephrectomy was compared using Cox proportional hazards regression analysis with inverse probability of treatment weighting. RESULTS: Cox regression analysis with inverse probability of treatment weighting revealed that volatile anesthesia had no impact on recurrence-free survival [hazard ratio (HR)=0.45; 95% confidence interval (CI)=0.07-2.85; p=0.398] or overall survival (HR=1.41; 95% CI=0.31-6.44; p=0.661). CONCLUSION: We found no significant association between volatile anesthesia and poor outcomes after nephrectomy for renal cell carcinoma. Volatile anesthetic-promoted metastatic potentiation of renal cell carcinoma, shown in a preclinical study, does not seem to be translated in the clinical setting.

Evaluation of the effects of total intravenous anesthesia and inhalation anesthesia on postoperative cognitive recovery.

OBJECTIVE: To compare the effects of total intravenous anesthesia (TIVA) and inhalation anesthesia (IA) used in lumbar disc herniectomy on postoperative cognitive recovery based on the mini-mental state examination (MMSE) score and neuron-specific enolase (NSE) levels. MATERIAL AND METHODS: The study sample consisted of 80 patients aged 18-65 years who were scheduled for elective lumbar disc herniectomy. The patients were divided into two groups according to the anesthesia technique applied, such as TIVA or IA. The patients in the TIVA group were administered remifentanil and propofol and those in the IA group were administered sevoflurane for maintenance. The MMSE was applied to the patients before the operation and 1h and 24 h postoperatively. Venous blood samples were obtained for the measurement of NSE before the operation and on the 24 h postoperatively. RESULTS: The mean preoperative MMSE scores were similar in the two groups. In the TIVA group, the preoperative and postoperative MMSE scores at 1 h were similar but were higher at 24 h postoperatively compared to the previous two scores (p = 0.001 and p < 0.001, respectively). In the IA group, the preoperative and postoperative 24 h MMSE scores were similar but lower at 1h postoperatively than the other two scores (p = 0.006 and p < 0.001, respectively). In the TIVA group, there was a significant decrease in the postoperative serum NSE levels than the preoperative values (p = 0.038). CONCLUSION: The use of IA may result in higher cognitive dysfunction 1h after the operation compared to TIVA. The effects of both methods on cognitive functions were similar at 24 h postoperatively.

Effects of two continuous infusion doses of lidocaine on isoflurane minimum anesthetic concentration in chickens.

OBJECTIVE: To assess the effect of two intravenous (IV) doses of lidocaine on the minimum anesthetic concentration (MAC) of isoflurane in chickens. STUDY DESIGN: Blinded, prospective, randomized, experimental crossover study. ANIMALS: A total of six adult female chickens weighing 1.90 ± 0.15 kg. METHODS: Chickens were anesthetized with isoflurane and mechanically ventilated. Isoflurane MAC values were determined (T0) in duplicate using an electrical noxious stimulus and the bracketing method. After MAC determination, a low dose (LD; 3 mg kg-1 followed by 3 mg kg-1 hour-1) or high dose (HD; 6 mg kg-1 followed by 6 mg kg-1 hour-1) of lidocaine was administered IV. MAC determination was repeated at 1.5 (T1.5) and 3 (T3) hours of lidocaine administration and blood was collected for analysis of plasma lidocaine and monoethylglycinexylidide (MEGX) concentrations. Pulse rate, peripheral hemoglobin oxygen saturation, noninvasive systolic arterial pressure and cloacal temperature were recorded at T0, T1.5 and T3. Treatments were separated by 1 week. Data were analyzed using mixed-effects model for repeated measures. RESULTS: MAC of isoflurane (mean ± standard deviation) at T0 was 1.47 ± 0.18%. MAC at T1.5 and T3 was 1.32 ± 0.27% and 1.26 ± 0.09% (treatment LD); and 1.28 ± 0.06% and 1.30 ± 0.06% (treatment HD). There were no significant differences between treatments or times. Maximum plasma lidocaine concentrations at T3 were 496 ± 98 and 1200 ± 286 ng mL-1 for treatments LD and HD, respectively, and were not significantly different from T1.5. With treatment HD, plasma concentration of MEGX was significantly higher at T3 than at T1.5. Physiological variables were not significantly different among times with either treatment. CONCLUSIONS AND CLINICAL RELEVANCE: Administration of lidocaine did not significantly change isoflurane MAC in chickens. Within treatments, plasma lidocaine concentrations were not significantly different at 1.5 and 3 hours.