Sevoflurane or Desflurane for COPD?

[deleted171991]

Actually real men shoot 120 mm

-bsd

Nope, those are real murderers.

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[periopdoc]

If I may point out that you cannot base your decisions on an article from 1998, when prices might have been much different (there was no generic sevo).

You could, if your argument is that the actual acquisition cost is the critical, and oft ignored, detail (and the cost of the two, at-the-time, on-patent volatiles came out the same as the off-patent Iso.) .

But, of course, I was just pointing out the ridiculous, internal inconsistencies and contradictions in the selected article.

The truth is that, where money is an issue, people tend to use sevo (plus nitrous) to achieve almost the same outcomes as with Des. What is really unfortunate is that I see more and more academic programs restricting Des, which is a crime against resident education.

A true crime. An even bigger crime is the apparent inability to do accurate consumption calculations, using molecular weights and flow rates, which I started doing as a CA-1. One has to use actual consumption rates and acquisition cost to determine which is cheaper. Also, although we treat nitrous like it is free, it isn't.

-bsd

 

[periopdoc]

Anyway, for LMA cases SEVO is the superior agent but for the obese or elderly DES wins hands down. POD is convinced DES is the way to fly for his cases so until he does a few thousand with SEVO his mind is made up.

While I will never achieve the same number of clinical anesthesia encounters that you have, I have roughly 2,000 personally performed, solo anesthetics with Sevo at this point in my career. Is that enough to make a reasonable call? I think so, someone else may feel differently. Can I get pretty damn close with Sevo? Sure, when I have a predictable surgeon on a predictable case, with no surprises.

I use it for all of my MRIs and I can have the patient awake and extubated predictably within a minute or two of finishing the case. MRI machines are markedly more predictable than surgeons.

With Des, I don't have to care if the surgeon decides, ok I'm done now, five minutes after telling me we have an hour or more. I don't have to worry about an over sedated patient in PACU.

Even if someone wants to argue it doesn't make my outcomes any different, it simply makes my job easier. At no increased cost, why wouldn't I want to make my job easier?

-bsd

 

[pjl]

At my PP hospital:
I removed iso from all machines except heart room and neuro/trauma rooms where patients frequently go to ICU intubated. We were spending a fair amount of money throwing away expired iso.

I use agents like Hawaiian Bruin:
Peds+MRI=Sevo
Intubated to ICU=Iso
All else (including LMA)=Des

I have not had issues with LMA spasm on Des.

I calculated our cost to be $14.xx/hr sevo vs $16.xx/hr des when used at typical flow rates using our pharmacy prices. I have not recalculated in a few years, but I dont think I really care. Our PACU time is ~$600 facility fee per 30 minutes, so if the patient can move along to Phase 2 a few minutes faster it can save them a pretty hefty chunk.






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[Noyac]

It's funny how we are debating so fercously the pros and cons of two extremely good anesthesic gases. Its not like one is head and shoulders above the other. I prefer DES but I can use Sevo any time and vice versa, as everyone else here can do. And most observers would have a very difficult time determining which agent was used. I think we would be better at determining which induction agent (propofol vs etomidate or STP) was used actually. But I apreciate the discussion nonetheless.

 

[BLADEMDA]

It's funny how we are debating so fercously the pros and cons of two extremely good anesthesic gases. Its not like one is head and shoulders above the other. I prefer DES but I can use Sevo any time and vice versa, as everyone else here can do. And most observers would have a very difficult time determining which agent was used. I think we would be better at determining which induction agent (propofol vs etomidate or STP) was used actually. But I apreciate the discussion nonetheless.

I might add that low dose Sevo (1/3 Mac) COMBINED WITH 60-70% NITROUS will almost match DES for wake-up speed in many situations. Des is the better agent in terms of emergence/Wake-up but the low dose SEVO with Nitrous runs a close second for the last 15 minutes of the case.

I appreciate POD's input on the topic but I think we can all move on.

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933493

 

[Noyac]

I might add that low dose Sevo (1/3 Mac) COMBINED WITH 60-70% NITROUS will almost match DES for wake-up speed in many situations. Des is the better agent in terms of emergence/Wake-up but the low dose SEVO with Nitrous runs a close second for the last 15 minutes of the case.

I appreciate POD's input on the topic but I think we can all move on.

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933493

Not so much at my altitude.

 

[periopdoc]

All in good fun. I would have enjoyed partnering with your group, Blade. The back and forth would have been fun. That being said, I have no regrets whatsoever.

-bsd

 

[Noyac]

Why not???

MOCA minute question calls neuromuscular relaxation an "absolute" contraindication to Pressure Support Mode.

I understand that we have a backup rate set so this is moot. But you see were my question comes in.

 

[psychbender]

^^ Therein lies one of the many problems with the MOCA minute (another is that I've had that question three times out of the sixty I've done so far). No one who has practiced in the modern era would think having any degree of neuromuscular blockade at all was absolute contraindication to PSV.

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[deleted171991]

^^ Therein lies one of the many problems with the MOCA minute (another is that I've had that question three times out of the sixty I've done so far). No one who has practiced in the modern era would think having any degree of neuromuscular blockade at all was absolute contraindication to PSV.

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Of course it is. Proper muscle relaxation, not 4/4 TOF.

PSV is not SIMV. There might not be a backup mode on an old machine.

 

[BLADEMDA]

^^ Therein lies one of the many problems with the MOCA minute (another is that I've had that question three times out of the sixty I've done so far). No one who has practiced in the modern era would think having any degree of neuromuscular blockade at all was absolute contraindication to PSV.

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It was in my day so older Anesthesiologists may still think that way. Our Ventilators were much simpler (think Narkomed 4- a tank but simple).

 

[BLADEMDA]

Best Anesthesia Machine ever invented (even with its simple ventilator):

 

[deleted171991]

Best Anesthesia Machine ever invented (even with its simple ventilator):

Definitely my kind of machine. I hate touch screens or multifunction knobs; dedicated knobs are safer and faster.

As an attending, I used to work with this 3-dial old analogic propofol pump, with exchangeable faceplates for various medications, a different one for every medication. What a pleasure, compared to the "smart" infusion pumps of my residency, which were designed to bureaucrat specifications.

 

[BLADEMDA]

Sure she's fancy and has all the bells and whistles but she could leave you standing at the door on prom night.

 

[Planktonmd]

MOCA minute question calls neuromuscular relaxation an "absolute" contraindication to Pressure Support Mode.

I understand that we have a backup rate set so this is moot. But you see were my question comes in.

It would be a contraindication if the muscle relaxation was so profound that the diaphragm was not even able to move to trigger pressure support, but if the patient is still able to trigger the vent then you can adjust your pressure support to give whatever tidal volume you want.
Obviously the minute question assumes that we are idiots and would paralyze a patient profoundly and then sit there and wait hoping they will trigger the vent on pressure support mode!
Was that the CRNAs minute question?

 

[deleted171991]

It would be a contraindication if the muscle relaxation was so profound that the diaphragm was not even able to move to trigger pressure support, but if the patient is still able to trigger the vent then you can adjust your pressure support to give whatever tidal volume you want.
Obviously the minute question assumes that we are idiots and would paralyze a patient profoundly and then sit there and wait hoping they will trigger the vent on pressure support mode!
Was that the CRNAs minute question?

Most anesthesiologists work with CRNAs, so what is safe with us might not be safe with them. Would you let the average CRNA put a muscle-relaxed patient on PSV?

There are cases I do solo with LMAs that I would only do with an ETT in an ACT model. Or cases I do solo without an artificial airway that I would never let a CRNA do the same way in my absence.

 

[BLADEMDA]

Definitely my kind of machine. I hate touch screens or multifunction knobs; dedicated knobs are safer and faster.

As an attending, I used to work with this 3-dial old analogic propofol pump, with exchangeable faceplates for various medications, a different one for every medication. What a pleasure, compared to the "smart" infusion pumps of my residency, which were designed to bureaucrat specifications.

Yep. That's what I used in the early 1990s. Simple and effective,

 

[Planktonmd]

Yep. That's what I used in the early 1990s. Simple and effective,

German technology... need I say more?

 

[deleted171991]

German technology... need I say more?

You mean like Volkswagen Diesel?

 

[Planktonmd]

You mean like Volkswagen Diesel?

Remember this marvelous invention??

 

[OB1🤙]

I love narkomeds. Miss them.

 

[BLADEMDA]

Anesthesia & Analgesia:
Post Author Corrections: March 28, 2016
doi: 10.1213/ANE.0000000000001296
Research Report: PDF Only
Inhaled Anesthetics Exert Different Protective Properties in a Mouse Model of Ventilator-Induced Lung Injury.
Strosing, Karl Michael MD, DESA; Faller, Simone PhD; Gyllenram, Veronica; Engelstaedter, Helen MD; Buerkle, Hartmut MD; Spassov, Sashko PhD; Hoetzel, Alexander MD, MA
Published Ahead-of-Print

Abstract

BACKGROUND: Mechanical ventilation is an important perioperative tool in anesthesia and a lifesaving treatment for respiratory failure, but it can lead to ventilator-associated lung injury. Inhaled anesthetics have demonstrated protective properties in various models of organ damage. We compared the lung-protective potential of inhaled sevoflurane, isoflurane, and desflurane in a mouse model of ventilator-induced lung injury (VILI).

METHODS: C57BL/6N mice were randomized into 5 groups (n = 8/group). One group served as a control and 4 groups were subjected to mechanical ventilation with air (12 mL/kg tidal volume) for 6 hours. Ventilated animals were anesthetized with either ketamine and acepromazine, or 1 of 3 inhaled anesthetics: isoflurane, sevoflurane, or desflurane. Lung injury was assessed by lung histology, neutrophil counts, and interleukin-1[beta] concentrations in bronchoalveolar lavage fluid. Antioxidant effects were explored by evaluation of production of reactive oxygen species (ROS) and glutathione content in lung tissue by immunofluorescence staining and confocal laser scanning microscopy. Changes in intercellular adhesion molecule-1 and src-protein-tyrosine-kinase levels were determined by real-time polymerase chain reaction and Western blot.

RESULTS: Compared with nonventilated controls, ventilated mice anesthetized with ketamine had thickened alveolar walls, elevated VILI scores, higher polymorph neutrophil counts, and increased ROS production. Mice anesthetized with isoflurane and sevoflurane showed thinner alveolar septa, lower VILI scores, lower polymorph neutrophil counts, and lower interleukin-1[beta] concentrations than ketamine mice. The expression of intercellular adhesion molecule-1/src-protein-tyrosine-kinase was neither affected by mechanical ventilation nor affected by administration of inhaled anesthetics. Mice anesthetized with isoflurane and sevoflurane showed less ROS production and higher glutathione contents compared with ketamine mice. Unexpectedly, desflurane-ventilated mice showed similar signs of lung injury compared with mice ventilated with air alone and receiving ketamine anesthesia. Desflurane failed to inhibit inflammatory responses and ROS production in lung tissue and developed no antioxidant potential.

CONCLUSIONS: Although isoflurane and sevoflurane prevent ventilator-associated lung injury, desflurane does not. As an underlying mechanism, both inhaled anesthetics exert major anti-inflammatory and antioxidative effects.

 

[BLADEMDA]

Recent study compared Volatile Anesthetic vs Propofol for Lung surgery. Guess which Inhalational they chose to use? Guess which one is the WORST inhalational anesthetic if you are trying to show superiority of Volatile agents vs Propofol?

see the next post

 

[BLADEMDA]

Perioperative Medicine | May 2016
Which Anesthesia Regimen Is Best to Reduce Morbidity and Mortality in Lung Surgery? A Multicenter Randomized Controlled Trial

Beatrice Beck-Schimmer, M.D.; John M. Bonvini, M.D.; Julia Braun, Ph.D.;Manfred Seeberger, M.D.; Thomas A. Neff, M.D.; Tobias J. Risch, M.D.; Frank Stüber, M.D.; Andreas Vogt, M.D.; Walter Weder, M.D.; Didier Schneiter, M.D.;Miodrag Filipovic, M.D.; Milo Puhan, M.D., Ph.D.


Background: One-lung ventilation during thoracic surgery is associated with hypoxia–reoxygenation injury in the deflated and subsequently reventilated lung. Numerous studies have reported volatile anesthesia–induced attenuation of inflammatory responses in such scenarios. If the effect also extends to clinical outcome is yet undetermined. We hypothesized that volatile anesthesia is superior to intravenous anesthesia regarding postoperative complications.

Methods: Five centers in Switzerland participated in the randomized controlled trial. Patients scheduled for lung surgery with one-lung ventilation were randomly assigned to one of two parallel arms to receive either propofol or desflurane as general anesthetic. Patients and surgeons were blinded to group allocation. Time to occurrence of the first major complication according to the Clavien-Dindo score was defined as primary (during hospitalization) or secondary (6-month follow-up) endpoint. Cox regression models were used with adjustment for prestratification variables and age.

Results: Of 767 screened patients, 460 were randomized and analyzed (n = 230 for each arm). Demographics, disease and intraoperative characteristics were comparable in both groups. Incidence of major complications during hospitalization was 16.5% in the propofol and 13.0% in the desflurane groups (hazard ratio for desflurane vs. propofol, 0.75; 95% CI, 0.46 to 1.22; P = 0.24). Incidence of major complications within 6 months from surgery was 40.4% in the propofol and 39.6% in the desflurane groups (hazard ratio for desflurane vs. propofol, 0.95; 95% CI, 0.71 to 1.28; P = 0.71).

Conclusions: This is the first multicenter randomized controlled trial addressing the effect of volatile versus intravenous anesthetics on major complications after lung surgery. No difference between the two anesthesia regimens was evident.

 

[BLADEMDA]

I'm not suggesting that Mortality would be any different in the study above regardless of the volatile agent; but, one could certainly postulate that Sevoflurane or Isoflurane may have had a positive impact in reducing morbidity postop.

I use Sevoflurane in this subgroup of patients based on the available clinical data to this point.

 

[Mman]

I'm not suggesting that Mortality would be any different in the study above regardless of the volatile agent; but, one could certainly postulate that Sevoflurane or Isoflurane may have had a positive impact in reducing morbidity postop.

I use Sevoflurane in this subgroup of patients based on the available clinical data to this point.

i would certainly hope your anesthetic choice wouldn't impact mortality or major morbidity in such a small study. Would probably need 5,000- 10,000 patients to start to show differences.

 

[BLADEMDA]

Perioperative Medicine | June 2016
Effects of Volatile Anesthetics on Mortality and Postoperative Pulmonary and Other Complications in Patients Undergoing Surgery: A Systematic Review and Meta-analysis
Christopher Uhlig, M.D.; Thomas Bluth, M.D.; Kristin Schwarz, M.Sc.; Stefanie Deckert, M.Sc.; Luise Heinrich, M.Sc.; Stefan De Hert, M.D., Ph.D.; Giovanni Landoni, M.D.; Ary Serpa Neto, M.D., Ph.D.; Marcus J. Schultz, M.D., Ph.D.;Paolo Pelosi, M.D., F.E.R.S.; Jochen Schmitt, M.D., Ph.D.; Marcelo Gama de Abreu, M.D., M.Sc., Ph.D., D.E.S.A.
Author Notes

Anesthesiology 6 2016, Vol.124, 1230-1245. doi:10.1097/ALN.0000000000001120



Background: It is not known whether modern volatile anesthetics are associated with less mortality and postoperative pulmonary or other complications in patients undergoing general anesthesia for surgery.

Methods: A systematic literature review was conducted for randomized controlled trials fulfilling following criteria: (1) population: adult patients undergoing general anesthesia for surgery; (2) intervention: patients receiving sevoflurane, desflurane, or isoflurane; (3) comparison: volatile anesthetics versus total IV anesthesia or volatile anesthetics; (4) reporting on: (a) mortality (primary outcome) and (b) postoperative pulmonary or other complications; (5) study design: randomized controlled trials. The authors pooled treatment effects following Peto odds ratio (OR) meta-analysis and network meta-analysis methods.

Results: Sixty-eight randomized controlled trials with 7,104 patients were retained for analysis. In cardiac surgery, volatile anesthetics were associated with reduced mortality (OR = 0.55; 95% CI, 0.35 to 0.85; P = 0.007), less pulmonary (OR = 0.71; 95% CI, 0.52 to 0.98; P = 0.038), and other complications (OR = 0.74; 95% CI, 0.58 to 0.95; P = 0.020). In noncardiac surgery, volatile anesthetics were not associated with reduced mortality (OR = 1.31; 95% CI, 0.83 to 2.05,P = 0.242) or lower incidences of pulmonary (OR = 0.67; 95% CI, 0.42 to 1.05; P = 0.081) and other complications (OR = 0.70; 95% CI, 0.46 to 1.05; P = 0.092).

Conclusions: In cardiac, but not in noncardiac, surgery, when compared to total IV anesthesia, general anesthesia with volatile anesthetics was associated with major benefits in outcome, including reduced mortality, as well as lower incidence of pulmonary and other complications. Further studies are warranted to address the impact of volatile anesthetics on outcome in noncardiac surgery.

 

[Mman]

cardiac surgery benefits likely via preconditioning. plenty of studies showing volatile anesthetics can provide similar benefit to ischemic preconditioning.