|Year : 2008 | Volume
| Issue : 5 | Page : 527
Comparison of the Effects of Sevoflurane, Desflurane and Totally Intravenous Anaesthesia with Propofol on Haemodynamic Variables Using Transesophageal Doppler
Selen Osmanagaoglu1, Hulya Ulusoy2, Mehmet Salih Colak3, Nesrin Erciyes4
1 Specialist, Medicine School of Karadeniz Technical University, Department of Anaesthesiology and Reanimation, 61080 Trabzon, Turkey
2 Associate Professor, Medicine School of Karadeniz Technical University, Department of Anaesthesiology and Reanimation, 61080 Trabzon, Turkey
3 Assistant Professor, Medicine School of Karadeniz Technical University, Department of Anaesthesiology and Reanimation, 61080 Trabzon, Turkey
4 Professor, Medicine School of Karadeniz Technical University, Department of Anaesthesiology and Reanimation, 61080 Trabzon, Turkey
|Date of Acceptance||07-Jul-2008|
|Date of Web Publication||19-Mar-2010|
Paris Cad. AnkaraApt. No:16/9, 06540 Kavaklidere/Ankara
Sevoflurane and desflurane inhalation anaesthetics are in routine use providing more rapid recovery than preexisting inhalation anaesthetics. We wanted to compare the effect of different anaesthetic agents on haemodynamic parameters with using transesophageal echo-Doppler in ASA I-II patients. A total of 45 American Society of Anesthesiologists (ASA) physical status I-II patients age between 18-65 scheduled for elective major abdominal surgery were admitted to this prospective randomized study and divided into three groups. Induction of anaesthesia was provided with 1µgkg -1 fentanyl, 6-8 mgkg -1 thiopenthal and 0.1 mgkg -1 vecuronium in sevoflurane (Group S, n=15), and desflurane (Group D, n=15), and 1µgkg -1 remifentanil, 2mgkg -1 propofol, and 0.1 mgkg -1 vecuronium in totally intravenous anaesthesia (TIVA) group (Group T; n=15). For maintenance of anaesthesia, patients received an infusion of 0.15 µgkg -1 min remifentanil, 4-6 mgkg -1 h -1 propofol, sevoflurane 2%, or desflurane 6% at 1.0 MAC. Bispectral index (BIS) values of 40-60 were targeted during operation. After endotracheal intubation, the haemodynamic and respiratory parameters, and BIS were recorded 5 min after the intubation (T 0 ), 30 min after the intubation (T 1 ), 60 min after the intubation (T 2 ) and before the extubation (T 3 ) with using haemodynamic monitoring (Hemosonic 100). After induction of anaesthetic agents, heart rate (HR) increased significantly in desflurane group (Group D) compared with group sevoflurane (Group S) and TIVA (Group T) groups at 5 min after the intubations, 30 min after the intubations, 60 min after the intubations and compared with group sevoflurane before the extubation. The Stroke Volume (SV) values increased significantly at the 5th minute intubation in Group S as compared to the Group D and in Group D as compared to the Group T. Compared with Group D, maximum acceleration (Acc) increased significanly in Group T before extubation. The BIS values were significantly lower in the Groups S and D at all the time intervals as compared to the Group T. Although a significant increase in HR and no significant decrease in Acc were noted in the desflurane group, sevoflurane and desflurane provided similar cardiovascular effects in the present study. The BIS values were significantly lower in the sevoflurane and desflurane groups compared with the TIVA.
Keywords: Transesophageal echo-Doppler, Sevoflurane, Desflurane, Totally intravenous anaesthesia, Haemodynamic variables
|How to cite this article:|
Osmanagaoglu S, Ulusoy H, Colak MS, Erciyes N. Comparison of the Effects of Sevoflurane, Desflurane and Totally Intravenous Anaesthesia with Propofol on Haemodynamic Variables Using Transesophageal Doppler. Indian J Anaesth 2008;52:527
|How to cite this URL:|
Osmanagaoglu S, Ulusoy H, Colak MS, Erciyes N. Comparison of the Effects of Sevoflurane, Desflurane and Totally Intravenous Anaesthesia with Propofol on Haemodynamic Variables Using Transesophageal Doppler. Indian J Anaesth [serial online] 2008 [cited 2013 May 24];52:527. Available from: http://www.ijaweb.org/text.asp?2008/52/5/527/60669
| Introduction|| |
Sevoflurane and desflurane inhalation anaesthetics are in routine use providing more rapid recovery than pre-existing inhalation anaesthetics. Both agents provide also a good stability of cardiovascular parameters during surgery. The most frequent haemodynamic sideeffect can be represented by hypotension and bradycardia, reasonably related to the depth of anaesthesia. It has been reported in healthy volunteers that desflurane increases HR through an activation of the sympathetic tone  , while sevoflurane showed less haemodynamic side effects than other agents like isoflurane. 
For their pharmacokinetic properties, propofol and remifentanil allow to obtain a good control of the haemodynamic parameters and a fast and safe recovery of consciousness . Dutchman et al  reported that the cause of bradycardia caused by propofol was related to the sympathetic system which was suppressed by propofol while the same suppressive effect was very weak for the parasympathetic system. In patients receiving TIVA have a lower heart rate compared with patients receiving sevoflurane. Hug et al found  that a 15-35% decrease in arterial pressure in the first 15 min of anaesthesia using propofol and it remained slightly lower compared with baseline.
Transesophageal monitoring of descending thoracic aortic blood flow using a combined M-mode and pulsed Doppler (TEEDS), Hemosonic™ 100, is an original device measuring simultaneously, and at the same anatomic level, aortic diameter, and blood flow velocity and allows assessment of preload, contractility, and after load of the heart. 
The objective of the study was to compare the effect of different anaesthetic agents on haemodynamic variables using Transesophageal echo-Doppler.
| Methods|| |
The study was approved by the Medical Ethics Committee of our University and a written informed consent was obtained from each patient who participated in this study. Forty five American Society of Anesthesiologists (ASA) physical status I-II patients age between 18-65 scheduled for elective major abdominal surgery with expected duration of more than 60 min, were included in this prospective randomized study. Patients with a history of esophageal disease, severe respiratory system disease, coronary ischemia, ventricular dysfunction or cardiac failure, with body mass index >30 kg.m -2 were excluded. All patients were premedicated with midazolam (0.05 mgkg -1 ) intra muscular before surgery. In the operating room before the anaesthesia induction, noninvasive monitors were used to record heart rate, mean arterial pressure, and oxygen saturation.
A total of 45 patients were randomized to three groups according to a generated randomization table and induction of anaesthesia were provided with 1µg.kg1 fentanyl, 6-8 mg.kg -1 thiopental and 0.1 mgkg -1 vecuronium in sevoflurane (Group S, n=15), and desflurane (Group D, n=15), and 1 µgkg -1 remifentanil, 2 mg.kg -1 propofol, and 0.1 mg.kg -1 vecuronium in TIVA group (Group T; n=15). Tracheal intubation was performed after administrating N 2 O/O 2 50% 3Lmin -1 in sevoflurane and desflurane groups; air/ O 2 50%, 3 Lmin1 in TIVA group and the end tidal anaesthetic concentrations had reached 1 MAC. For maintenance of anaesthesia, patients received an infusion of 0.15 µg.kg -1 min -1 remifentanil, 4-6 mg.kg -1. h -1 propofol, sevoflurane 2% or desflurane 6% at 1.0 MAC. The primary maintenance anaesthetic was subsequently titrated to maintain a target of bispectral index (BIS) value between 40-60 during operation. An arterial cannula, central venous pressure (CVP) and Foley catheters were administrated to all patients during surgery. Central venous pressure was measured from a peripheral intravenous cannula in order to maintain the CVP value between 812 cmH 2 O. After endotracheal intubation, a haemodynamic monitoring (Hemosonic 100) was performed. The haemodynamic and respiratory parameters, and bispectral index were recorded 5 min after the intubation (t 0 ), 30 min after the intubation (t 1 ), 60 min after the intubation (t 2 ) and before the extubation (t 3 ).
For statistic data processing tests were used: Kruskal-Wallis, Mann-Whitney and Student t test. The X2 test was used to compare differences in sex ratios, operation types and ASAs between the three groups. Data were presented as mean values ± SD, numbers, or percentages, with P values of less than 0.05 considered statistically significant.
| Results|| |
The three groups were similar with respect to their demographic characteristics and ASA classification (P>0.05) [Table 1]. After induction of anaesthetics, HR increased significantly in desflurane group (Group D) (compared with group sevoflurane (Group S) and TIVA (Group T) groups at 5 min after the intubation, 30 min after the intubation, 60 min after the intubation (P<0.05) and compared with group sevoflurane before the extubation. The SV values increased significantly at the 5th minutes intubation in group sevoflurane as compared to the group desflurane (P<0.05) and in desflurane group as compared to the TIVA group (P<0.05) [Table 2]. Compared with group desflurane, Acc increased significanly in TIVA group before extubation (P<0.05) [Table 3]. There was no statistically difference between three groups with regard to MAP, ABF, CO, Sva, TSVR, TSVRa, TSVRi, PV, LVETi, CI, SI, Dia, SpO 2 , EtCO 2 , PaO 2 , PaCO 2 , SaO 2 , HCO 3 - and pH values at T 0 , T 1 , T 2 and T 3 intervals [Table 4]. The BIS values were significantly lower in the Groups sevoflurane and desflurane at all the time intervals as compared to the TIVA group [Table 4].
| Discussion|| |
Transesophageal Doppler-derived CO measurements have given inconsistent results in the literature. Some authors claimed that the new technique is at least as accurate as thermodilution, which is a standard clinical method 7 whereas others showed that it was not  . Limitations of transesophageal sonography are usually encountered when the esophageal/aortic anatomy precludes a good sonography window, which occurs in about 15% of cases.  Possible disadvantages of transesophageal echo-Doppler devices are frequent repositioning of the transducer, poor signal during manipulations in the aorta, and the use of electrosurgery  . In addition, there are considerable complications including pharyngeal bleeding, transient laryngeal nerve paralysis, esophageal perforation, dysrhyhmias, aspiration, congestive heart failure and hypotension due to great vessel occlusion. In the present study, a poor signal during repositioning of the patient and when using of electrosurgery has only occurred. These losses were occasional and transient. Therefore, we suggested that beeing a semi-invasive and relatively cheap method, transesophageal echo-Doppler can be used more widely as an alternative reliable method in ASA I-II patients. However, further studies with larger numbers of patients are needed to determine the technical problems and the cardiovascular complications due to the transesophageal echo-Doppler during surgery.
Desflurane provides more rapid induction, recovery and haemodynamical stability than preexisting inhalation anaesthetics, such as halothane, enflurane, and isoflurane  . Sevoflurane differs from desflurane in carbon dioxide absorbents which are stable in desflurane. Desflurane undergoes much less hepatic biotransformation than sevoflurane and desflurane may produce hypotension and tachycardia at higher concentrations  . In a study of Malan et al  , it has been found that the cardiovascular effects of sevoflurane were similar to those of isoflurane; sevoflurane did not alter heart rate, but decreased mean arterial pressure and mean pulmonary artery pressure (2.0 MAC sevoflurane, 1.5 and 2.0 MAC isoflurane). A rapid increase of desflurane concentration in humans increases sympathetic activity and hormonal variables and heart rate and arterial blood pressure more than does an equivalent increase in isoflurane concentration  . Frink et al  compared blood pressure and heart rate changes in healthy patients during anaesthesia with sevoflurane versus isoflurane and they found that sevoflurane and isoflurane produced similar systolic and diastolic arterial blood pressures, but heart rate after incision was faster in patients given isoflurane.
On the other hand, Gravel et al  compared the haemodynamic effects of sevoflurane when used for induction and maintenance of anaesthesia with a total intravenous technique in thirty patients with known coronary artery disease and they found that more patients in the sevoflurane group presented bradycardia in the induction period and also during maintenance of anaesthesia, treatment of hypertension was more frequent in the total intravenous technique group than in the sevoflurane group. During induction, propofol decreases the systolic and diastolic blood pressure by approximately 20-40 percent with minimal change in heart rate  . The initial propofol-mediated decrease in arterial blood pressure continued during anaesthesia without a simultaneous increase in heart rate or the pulse rate did not change  . In a study of Piat et al  which was designed to compare induction and recovery characteristics of sevoflurane and halothane anaesthesia in children, the inspired concentrations used for inhalation via a mask were 2%, 4%, 6%, and 7% for sevoflurane group, a significant increase in HR was observed before tracheal intubation in the sevoflurane group while HR and systolic arterial pressure did not change compared to control values during maintenance of anesthesia. In a study of Ebert et al  . Although an increasing of the sevoflurane concentration was found to be associated with lower sympathetic nerve activity and central venous pressure, the mean arterial pressure and heart rate of sevoflurane were similar with that of desflurane  . In this study, HR was found to be increased significantly in desflurane group compared with sevoflurane and TIVA groups at 5, 30 and 60 min after the intubation and only in desflurane group compared with sevoflurane before the extubation. In addition, because of the MAP values at T 0 , T 1 , T 2 and T 3 intervals failed to demonstrate any significant differences between the three anaesthetics, we concluded that the cardiovascular effects of sevoflurane were similar to those of desflurane and TIVA. All of them can reduce sympathetic stimulation of the vascular system leading to a decreased cardiac output accompanied by vasodilation, causing hypotension.
In the chronically instrumented dog, which was randomly assigned to two groups, receiving 1.2 and 2 MAC of sevoflurane or isoflurane, sevoflurane produced dose-dependent aortic hypotension, systemic vasodilation, dose-dependent decrease in stroke volume, and dose-dependent decrease in maximal rate of left ventricular pressure rise (dP/dt). Cardiac output decreased only at 2 MAC  . In contrast to study of Ebert et al  no statistically difference was found in the present study between three groups with regard to SVR and CO values at T 0 , T 1 , T 2 and T 3 intervals. We concluded that this result was correlated with TSVRa (no difference was found between the three groups with regard to TSVRa). Because, monitoring arterial pressures and SVR in conjunction with stroke volume (SV) can provide an assessment of afterload  .
Sevoflurane decreases myocardial contractility in a manner similar to equianaesthetic concentrations of isoflurane and desflurane, and does not potentiate epinephrine-induced cardiac arrhythmias. Sevoflurane reduces baroreflex function in a manner similar to other volatile anaesthetics. Although there is a controversy in the literature about the effects of inhalational anaesthetic agents on cardiovascular system  , consistent with previous reports , , sevoflurane and desflurane provided the same haemodynamic stability on cardiovascular system in the present study.
Maximum acceleration of the aortic flow (Acc) is a sensitive indicator of global left ventricular performance and myocardial contractility  . A comparison of Acc with SV provides a useful indication of preload  . It has been reported that desflurane, isoflurane and sevoflurane produced decreases in myocardial contractility in chronically instrumented dogs with autonomic nervous system blockade  . In the present study, we showed that Acc increased significantly in TIVA group before extubation when compared to the desflurane group. In contrast, in sevoflurane group when compared to desflurane and TIVA groups at T 0 , T 1 , T 2 and T 3 intervals, no statistically difference was found. However, the Acc values were much higher in the TIVA group than those of in desflurane and sevoflurane groups. We speculated that if there is no change in preload (left ventricular end-diastolic volume), after load (resistance to ventricular ejection) will decrease in parallel with decreasing the myocardial contractility. Malan et al  reported that at 1.0 and 1.5 MAC, although sevoflurane caused evidence of myocardial depression, the cardiovascular effects of sevoflurane were similar to those of isoflurane in healthy volunteers. When it has been considered Acc together with SV, the combination of them are correlated closely with changes in preload and left ventricular performance. Even there is a hypovolemic condition; a fall in SV with normal Acc value can show a "good" left ventricular performance  .Although the SV values increased significantly at the 5th minute intubations in-group sevoflurane as compared to the group desflurane and in desflurane group as compared to the TIVA group in the present study, preload remained almost constant. One possible explanation is that because of adequate initial colloid fluid infusion and preload was little affected by desflurane or TIVA. Thus, LVET i , with regard to the left ventricular ejection time (LVET i ) which is the time interval between the opening and closing of aortic valve (beginning and termination of aortic flow) and which is reported to correlate closely with changes in preload  , no statistically difference was found between three groups in the present study. Finally, although the number of cases was relatively small, any patients complicated with myocardial ischemia during this study, which might influence the LVET i values.
In this study, the BIS values of 40-60 were targeted at To , T 1 , T 2 and T 3 intervals. In a study of Nakayama et al  , the BIS value was found to be decreased from 95-96 to 39-38 before intubations in the isoflurane and sevoflurane groups with 2 MAC, respectively. They concluded that isoflurane and sevoflurane was effective to suppress the change in BIS due to intubations. Mi et al  observed the changes in EEG BIS with haemodynamic changes to intubations during induction with propofol or propofol and 2 µg.kg -1 fentanyl i.v, and they found that the BIS values were not different between treatment groups before and after intubations. In this study, we found that the BIS values were significantly lower in the Groups sevoflurane and desflurane at all the time intervals as compared to the TIVA group.
In conclusion, although a significant increase in HR and no significant decrease in Acc were noted in the desflurane group, sevoflurane and desflurane provided similar cardiovascular effects in the present study. The BIS values providing an adequate anaesthesia, were significantly lower in the sevoflurane and desflurane groups compared with the TIVA.
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[Table 1], [Table 2], [Table 3], [Table 4]