|Ahead of print publication
Desflurane versus sevoflurane in laparoscopic cholecystectomy: A comparison of recovery profile and home discharge in Indian patients
Divya Gahlot, Sharmila Ahuja, Neha Yadav, Sujata Choudhary
Department of Anaesthsia, University College of Medical Sciences and GTB Hospital, New Delhi, India
|Date of Submission||09-Jun-2020|
|Date of Decision||07-Jul-2020|
|Date of Acceptance||07-Jul-2020|
D-55 Aryanagar Apartments, I.P Extension, Patparganj, New Delhi - 110 092
Source of Support: None, Conflict of Interest: None
Context: Laparoscopic cholecystectomy is one of the most commonly performed minimal access surgeries nationwide, safely done as a day care procedure. Anesthetic techniques facilitating early recovery and home discharge have become the need of the hour. Aims: To compare early, intermediate, late recovery characteristics and time to home readiness following use of sevoflurane or desflurane as maintenance anesthesia in laparoscopic cholecystectomy in Indian subpopulation. In addition, postoperative complications such as coughing and shivering and total antiemetic and analgesic requirements postoperatively were also noted. Settings and Design: This was a prospective randomized study, and randomization was done by computerized random number table into two groups (30 patients in each group). Group S received sevoflurane and Group D received desflurane as maintenance agent. Subjects and Methods: Sixty patients of age group 18–60 years belonging to the American Society of Anesthesiologists Grade I and II undergoing laparoscopic cholecystectomy were recruited. A standard anesthesia induction was done and airway was secured with a ProSeal laryngeal mask airway of appropriate size. The patients subsequently received either sevoflurane 1%–2% or desflurane 3%–6% with 60% N2O in O2 as per group assigned. Inhalational agent was discontinued at the time of endoscope removal. Early, intermediate, and late recovery parameters were noted. Statistical Analysis: The tests of significance used were parametric test (unpaired t-test) and ANOVA. The outcome measures were compared statistically using unpaired t-test and ANOVA, and P < 0.05 was considered statistically significant. Results: Early recovery parameters were achieved faster in patients receiving desflurane as compared to sevoflurane with no difference in time to achieve intermediate recovery and home readiness. Conclusion: Despite a faster early recovery with desflurane, no additional benefit in terms of home discharge and patient satisfaction was found, thus making use of either of the agents suitable for laparoscopic cholecystectomy on a day care basis.
Keywords: Cholecystectomy, day care, desflurane, laparoscopic, postoperative recovery, sevoflurane
|How to cite this URL:|
Gahlot D, Ahuja S, Yadav N, Choudhary S. Desflurane versus sevoflurane in laparoscopic cholecystectomy: A comparison of recovery profile and home discharge in Indian patients. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Mar 2]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=308723
| Introduction|| |
Laparoscopic cholecystectomy is one of the most commonly performed surgeries worldwide and is considered as the gold standard surgery for cholelithiasis. It is safely performed as a day care procedure because of its several advantages such as faster recovery, shorter hospital stay, and early return to routine work activities.,,[s4] Therefore, use of anesthetic agents and techniques that facilitates early recovery when maintaining adequate depth of anesthesia is essential.
Inhalational agents of recent interest are sevoflurane and desflurane due to their favorable pharmacokinetic profile. Lower blood: gas partition coefficient of sevoflurane and desflurane facilitates a faster emergence from anesthesia as compared to traditional agents. Few studies have demonstrated a rapid awakening after desflurane compared to sevoflurane anesthesia.,6],,,, However, the data regarding the effect of these agents on recovery profile and home discharge in Indian population undergoing laparoscopic cholecystectomy are limited.
This study aims to compare early, intermediate, late recovery characteristics and time to home readiness [Table 1] following use of sevoflurane or desflurane as maintenance anesthesia in laparoscopic cholecystectomy in Indian subpopulation. In addition, postoperative complications such as coughing and shivering and total antiemetic and analgesic requirements postoperatively were also noted.
| Subjects and Methods|| |
An ethical committee approval (dated October 30, 2014) was obtained, and written informed consent was taken from all the patients included in the study. This was a prospective randomized study. Randomization was done by computerized random number table and patients were categorized into two groups of 30 patients each. Group S received sevoflurane and Group D received desflurane as maintenance agent in 60% N2O in O2. The study was conducted over a period of 1.5 year. Bias was avoided by ensuring that the parameters were noted by an observer different from the one using the inhalational agents intraoperatively.
Sixty patients with uncomplicated gallstone disease of age group 18–60 years belonging to the American Society of Anesthesiologists Grade I and II undergoing laparoscopic cholecystectomy were recruited in the study. Patients with cardiorespiratory disease, renal disease, hepatic disease, metabolic disease, neurological and psychiatric disorder, history of drug and alcohol abuse, and morbid obesity were excluded from the study.
A routine preoperative assessment was carried out on all patients, and the patients were familiarized with the procedure of general anesthesia. Tablet alprazolam 0.25 mg and tablet ranitidine 150 mg were given as oral premedication on night before and morning of surgery with a sip of water. All the patients were kept fasting for 6 h for solids and for 2 h for clear liquids. In operation room, monitors were attached and baseline reading of noninvasive blood pressure (NIBP), heart rate (HR), and pulse oximetry was noted and intravenous (IV) cannulation was secured. All the patients were preoxygenated for 3 min with 100% oxygen. Induction of anesthesia was done with injection fentanyl 2 μg/kg and injection propofol 2 mg/kg IV, injection vecuronium 0.1 mg/kg was given for muscle relaxation, and airway was secured with a ProSeal laryngeal mask airway (LMA) of appropriate size. During induction, flow rates were maintained at 8–10 l/min with dial concentration of 2% with sevoflurane and 6% with desflurane in 50% N2O in O2 as per group assigned using a closed anesthesia breathing system. After achieving a minimum alveolar concentration (MAC) value of 1.2, fresh gas flow rates were reduced to and maintained at 3 l/min intraoperatively. Gas monitoring was done throughout the procedure and total MAC was maintained between 1.2 and 1.3. The bispectral index (BIS) monitor was also used for monitoring depth of anesthesia keeping the target reading between 40 and 60. Muscle relaxation was maintained using intermittent doses of vecuronium at appropriate intervals. It was ensured that no muscle relaxant was given after clipping of bile duct. Pulse oximetry, NIBP, HR, and EtCO2 were monitored every 5 min. EtCO2 was maintained between 32–36 mmHg. Before the end of surgery, injection ondansetron 0.1 mg/kg IV was administered to all the patients for emetic prophylaxis and injection diclofenac 75 mg IV was given for analgesia. Inhalational agents used for maintenance of anesthesia were discontinued after removal of endoscope and neuromuscular block was reversed with injection glycopyrrolate 0.008 mg/kg and injection neostigmine 0.05 mg/kg IV. Port site infiltration was done 0.25% bupivacaine. Fresh gas flow rate was increased to 8–10 l/min with 50% N2O in O2. N2O was discontinued after application of the last skin suture. After ensuring a regular breathing and achieving MAC of 0.15–0.3, ProSeal LMA was removed. Time of removal of airway device, time for eye opening, time to follow verbal commands, and time to orientation (when the patient was able to tell his/her name) were noted as early recovery parameters at 30 s, 60 s, 90 s, 120 s, 150 s, 180 s, and every 30 s afterward from time of discontinuation of inhalational agent.
After achieving early recovery parameters, patients were shifted to postanesthesia care unit (PACU). In PACU, fast-track eligibility criteria were followed to measure intermediate recovery parameters every 15 min. Fast-track eligibility criteria comprise level of consciousness, physical activity, respiratory instability, oxygen saturation status, postoperative pain, and emetic assessment with a total score of 14 [Table 2]. Time of achieving score of ≥12 was considered sufficient for discharge from PACU to ward. Injection ondansetron 1 mg IV and injection dexamethasone 6 mg IV were used as a rescue antiemetic and paracetamol IV was administered as a rescue analgesia in PACU.
Late recovery parameters were noted in the ward, which included time to resume sitting, time to walk, time of first oral intake, and time taken for readiness to home discharge. Patients were allowed ambulation as early as possible and respective time was noted. Oral intake was started when patients accepted oral feed without nausea and vomiting, and the time of first oral intake was noted as well. Revised PADS score was used to determine home readiness and was found to be effective and easy to use., Revised PADS score includes vital parameters, activity level, nausea and vomiting, pain, and surgical bleeding and has a total score of 10 [Table 3]. After achieving a score of ≥9, patients were considered fit for home discharge. Those patients where duration of surgery exceeded 90 min due to surgical reasons and procedure was converted to open cholecystectomy were excluded from the study.
After setting type I error of 5% and power of study to be 90%, the required sample size was calculated to be 15 in each group. However, the tests of significance used are parametric test, namely, unpaired t-test and ANOVA, which requires normal distribution of variable; thus, to ensure normal distribution of variables, we recruited 30 patients in each group. This sample size was calculated using G-Power (version 188.8.131.52) Germany: GmbH.
The data were entered into a Microsoft Excel spreadsheet and the statistical analysis was done using SPSS software version 20 IBM SPSS statistics for windows, version 20.0. (Armonk, NY: IBM Corp.). The outcome measures were compared statistically using unpaired t-test and ANOVA, and P < 0.05 was considered statistically significant.
| Results|| |
The demographic profile of all the patients and the total duration of surgery was comparable in both the groups with no statistical significant difference [Table 4].
There was no difference in mean arterial pressure (MAP) and HR intraoperatively between the two groups. A gradual fall in HR was observed after induction of anesthesia within the group which was comparable between the groups.
- Early recovery parameters – The time from discontinuation of inhalational agent to removal of airway device, time to follow verbal commands, time to eye opening, and time to orient were significantly faster and statistically significant in patients receiving desflurane as compared to patients receiving sevoflurane [Table 5]
- Intermediate recovery parameters – Patients in the desflurane group achieved fast-track score of 12 earlier than sevoflurane group, but this difference was not statistically significant [Table 6]
- Late recovery parameters – The time of achieving late recovery parameters was comparable between the two groups with no statistically significant difference [Table 7]. All the patients achieved home readiness (achieving revised PADS score ≥9) by 24 h in both the groups. There was no difference in the incidence of postoperative complications such as coughing and shivering and total analgesic and antiemetic requirements between the two groups. Patient satisfaction score was noted at the end of 24 h postoperative period and all the patients were satisfied with the anesthesia experience.
| Discussion|| |
Laparoscopic cholecystectomy is one of the most frequently performed minimal access surgeries in our country and it bears a significant economic and financial share of the hospitals. It is routinely performed as a day care procedure in Western world. With the advent of newer and better anesthesia techniques, an early home discharge can be achieved for these patients in our settings as well, thus reducing monetary burden on the state.
The results of our study indicate that early recovery parameters were achieved faster in patients receiving desflurane as compared to those receiving sevoflurane with no difference in time to achieve intermediate recovery. Furthermore, by 24 h, all the patients in both the groups achieved a revised PADS score ≥9, and no difference was found in achieving home readiness between the two groups. Various studies by different authors have demonstrated a rapid awakening after desflurane compared to sevoflurane anesthesia, as determined by the time to eye opening, regaining of orientation, and ability to follow commands, with no difference in intermediate and late recovery parameters.,6],,,, The findings of our study was consistent with these authors, manifesting that despite a faster early recovery with desflurane anesthesia, there was no difference in early home discharge with this agent.
However, one study by Fanelli et al. in patients undergoing laparoscopic cholecystectomy reported a faster emergence as well as faster PACU discharge (intermediate recovery) with desflurane–remifentanil than sevoflurane–remifentanil. Use of remifentanil, an ultra-short-acting opioid fastened the PACU discharge in the above-mentioned study in the desflurane group. Mahmoud et al. reported faster emergence as well as early home discharge with desflurane as compared to sevoflurane. However, the author mentions the home discharge observation to be an insensitive measure as it was noted by the regular nursing staff and might have been partly influenced by established habits of the day ward.
Use of supraglottic airway device (ProSeal LMA) and increasing the flow rates during reversal helped us achieve a much shorter time to early recovery parameters as compared to previous studies.,, All patients were found to tolerate ProSeal LMA very well with no respiratory or airway-related complication during extubation. BIS monitoring was continued throughout the procedure which confirmed an adequate depth of anesthesia.
Desflurane, owing to its greater pungency as compared to sevoflurane, is known to have a higher incidence of airway-related complications such as coughing, laryngospasm, and bronchospasm. [18,19] Our study found no difference in respiratory-related complications between the two groups. Use of IV induction with propofol and fentanyl minimized the airway reflexes resulting in absence of any airway-related complication during induction.
A fall in HR and MAP following induction was observed in both the groups, but hemodynamic stability was maintained in all the patients. This change was within ±20% of baseline value and did not require any intervention.
Desflurane results in rapid early recovery from anesthesia undergoing laparoscopic cholecystectomy as compared to sevoflurane. Thus, benefits of early recovery may make use of desflurane more desirable. However, as both the agents achieved home readiness by 24 h with no significant incidence of postoperative complications such as shivering and emesis, despite a faster early recovery with desflurane, it offers no additional benefit in terms of home discharge and patient satisfaction. Further, these findings need to be supported with more evidence and with a larger sample size to add to the research data. Our study has certain limitations, in that the cost-effectiveness in terms of MAC hours for both the agents was not measured, and the study was not blinded.
Assessment of intermediate and late recovery parameters using fast-track eligibility score and revised PADS score was found to be easy to apply and indicated accurate recovery. Thus, we conclude that despite a rapid early recovery with desflurane as compared to sevoflurane, both the agents can achieve a similar intermediate recovery (PACU discharge) and home readiness at the end of 24 h with no difference in the incidence postoperative complications, thus ensuring use of either of the agents suitable for laparoscopic cholecystectomy in Indian population on a day care basis.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]