Official Journals By StatPerson Publication
Table of Content - Volume 12 Issue 3 -December 2019
Chaitali Shashikant Patil1*, Pradip Shivsambh Swami2
1Specialty Medical Officer, 2Additional Professor, Department of Anaesthesiology, Topiwala National Medical College and B.Y.L. Nair Hospital Mumbai Email: chaitalipatil92@gmail.com
Abstract Background: The use of inhalational agents such as desflurane, sevoflurane made the postoperative recovery easy for the patients. These volatile anaesthetic agents give early postoperative recovery as compared with older ones. Aim: To study the effect of sevoflurane and desflurane on hemodynamic parameters and recovery characteristics in patients undergoing laparoscopic gynaecologyical surgeries. Material and Methods: A total 60 female patients scheduled for elective laparoscopic gynaecological surgery were randomly allocated into two groups of each with the help of a computer-generated table of random numbers. Group S (n=30): received inhalational agent sevoflurane induction and maintenance anaesthesia. Group D (n=30): received inhalational desflurane induction and maintenance anaesthesia. Results: The hemodynamic parameters observed intraoperatively and after creating pneumoperitoneum were comparable in both the groups. The difference between them was statistically non-significant. (p>0.05). Postoperative recovery profile was better with desflurane as compared with sevoflurane. Cognitive functions and Modified Alderate score were statistically significant between two groups. (p value <0.05). The achievement of modified alderate score was early in desflurane. Conclusion: Desflurane and sevoflurane does not differ in intraoperative and postoperative hemodynamic parameters, and postoperative adverse effects, however early recovery is achieved with desflurane. Desflurane is better choice in ambulatory laparoscopic gynaecological surgeries. Key Words: Laparoscopic gynaecological surgeries, desflurane, sevoflurane, hemodynamic parameters, Modified Alderate score INTRODUCTION MATERIAL AND METHODS
Detailed history and systemic examination were done. Investigations (Complete blood count, X ray chest, urine routine and microscopy, ECG, LFT, RFT plus any other investigation carried out as per the requirement of surgery) checked and noted. After taking the patient in the operation theatre all the monitors were attached (Non-Invasive blood pressure cuff, pulse oximeter, Cardio scope) and baseline parameters noted. Monitoring included oxygen saturation, Systolic and Diastolic Blood pressure, Mean Arterial blood pressure, ECG, etco2, Gas flow for creating Pneumoperitoneum and Intra-abdominal pressure. An IV line was taken on the dorsum of the hand and an IV fluid (Ringer lactate) started. Fluids administered according to Holiday –Segar formula. Premedication Inj. glycopyrrolate (4μg/kg), midazolam (0.05mg/kg) and fentanyl (2μg/kg) was given to the patients. Patients preoxygenated for 3 minutes. Patient was induced with inj. Thiopentone sodium (5mg/kg). Only after confirming that the patient can be ventilated by mask (100% oxygen given for 2-3 minutes) a long acting muscle relaxant Inj Atracurium 0.5 mg/kg was administered. Direct Laryngoscopy done. After visualization of Vocal Cords an appropriately sized Portex cuffed endotracheal tube (no. 6.5 or 7 for females) was inserted under direct vision till cuff goes beyond the Vocal cords. Cuff inflated, Air entry checked. After confirming, clear and equal entry of air bilaterally, Tube secured in place and closed circuit connected. Anaesthesia was maintained on Oxygen + Air + Sevoflurane or Desflurane and intermittent bolus of muscle relaxant. Patient received Inhalational anesthetic agent Sevoflurane 1-2% or Desflurane 5-6%. Patients was mechanically ventilated to keep carbon dioxide 30-40mmHg. Using flows of 2lit/min in closed circuit. Intra-abdominal pressure was always maintained below 14 mm of Hg in all patients. Intraoperatively, hemodynamic parameters such as Pulse rate, Blood pressure (Systolic blood pressure, Diastolic Blood pressure, mean arterial blood pressure, ETCO2) recorded before start of the procedure (Baseline parameters), After administering the inhalational agent to be studied. 1 minute after induction, 1 minute after intubation, after skin incision, after creating pneumoperitoneum, 1 minute later and once in every 15 minutes till deflation of pneumoperitoneum, after deflation and after extubation. All patients received Inj. Paracetamol 10 mg/kg over 20 minutes prior to extubation. After Skin closure, after meeting extubation criteria, Suctioning done, Inj. Glycopyrrolate (4μg/kg), Inj. Neostigmine (0.05mg/kg) given. Postoperatively, patient was assessed in PACU for the quality of recovery in terms of hemodynamic parameters (pulse rate, Blood pressure), sedation scale and any adverse effect such as nausea, vomiting. Patients assessed every 15 minutes for 1 hour, every 30 minutes for next 1 hour, every hourly for next 2 hours (intermediate recovery). Totally for 4 hours quality of recovery profile assessed. After 4 hours of monitoring, patient was shifted from the recovery after achieving Modified Aldrete score of 9 or 10 out of 10. No additional intervention required in both the groups.
Statistical analysis RESULTS In our study mean age of group D was 29.6±6.3 and group S was 30±6.19. ASA status, in group D was 1.07±0.254 and in group S was 1.03±0.138. The mean weight of group D was 61.37±5.62 and group S was 61.4±4.87. The mean height in group D was 157.73±6.08 cm and group S was 159.2±5.47 cm. Table no.1 shows the comparison between age, weight, height, and ASA grading. The difference between group D and group S was statistically non-significant (p>0.05).
Table 1: Distribution of patient characteristics
After intubation and after skin incision heart rate of both the groups have increased up to ±20% of the baseline value. The heart rate in both groups were comparable. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals mentioned above. After creating pneumoperitoneum, the heart rate in both groups were comparable for all time intervals. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals mentioned above. Table 2: Mean heart rate at various intervals
After intubation and after skin incision SBP and DBP of both the groups have increased up to ± 20% of the baseline value. The SBP and DBP in both groups were2 comparable. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals. (Table 3).
Table 3: Mean systolic and diastolic blood pressure (mmHg) at various intervals
In present study, response to painful stimulus calculated for both the groups. It was achieved in the group D in (2.50 ± 0.799) minutes and in group S in around (3.89 ±0.930) minutes. (p=0.000). The difference was statistically highly significant. It indicates that response to painful stimulus was achieved earlier in patients who received desflurane as compared to patients who received sevoflurane. For spontaneous eye-opening patients who received desflurane took (3.19±0.794) minutes and who received sevoflurane took (4.94±0.74) minutes. The difference was statistically significant between two groups (p=0.000). Obeying commands in group D was achieved within (2.78±0.67) minutes and in group S was achieved within (4.28±0.633) minutes. Limb lift in group D achieved within (5.04±0.834) minutes and group S achieved in (7.73±1.08) minutes. The difference was statistically significant between two groups (p<0.0001). Table 4: Inter group Comparison of others and modified alderate score
Drowsiness were found out in 1 patient in group D and 1 in group S. There were 10 patients presented with PONV who received desflurane and 14 patients who received sevoflurane. Sore throat was present in 3 patients receiving desflurane and in 1 patient receiving sevoflurane. All these parameters were statistically analysed by using chi-square test in which result came nonsignificant for all the parameters p>0.05. DISCUSSION In our study demographic parameters like age, body weight, height and ASA classification were noted and analysed statistically between two groups by using student ‘t’ test. The difference between group D and group S was statistically non-significant (p>0.05). Chudasama PA et al who studied the Comparison of haemodynamic parameters and recovery characteristics between sevoflurane and desflurane in patients undergoing day-care surgical procedure. All demographic parameters are comparable in their study.3 White PF et al studied desflurane versus sevoflurane for maintenance of outpatient anesthesia and the effect on early versus late recovery and perioperative coughing. The two study groups had comparable demographic characteristics.4 Our findings were consistent with above study. The MAP in both groups were comparable for all time intervals. There was no statistical significance found by applying student t-test. (p>0.05) for all the time intervals. Jindal et al suggested that desflurane and sevoflurane both provide similar haemodynamic conditions during maintenance period.5 Patel et al suggested that sevoflurane and desflurane both provide similar intraoperative haemodynamic condition during maintenance period.6 Nathanson et al found that intraoperative haemodynamic parameters are same with both the groups.7 Gergin et al concluded that desflurane, like sevoflurane, maintains haemodynamic stability during intraoperative period.8 Our findings were consistent with all above studies. Intraoperative parameters studied by Chudasama PA et al depicts that desflurane gives more hemodynamic stable picture in day care surgeries. In our study the findings regarding intraoperative hemodynamic parameters were inconsistent with this study.3 In our study we found out that achievement of modified Alderate score was earlier in desflurane group. In Jindal et al study time to achieve modified alderate score in group D was (10.8 ± 3.77) minutes and in group S was (16.2 ± 3.87) minutes. Our result is consistent with above study.5 Patel et al study stated that the response to painful stimuli, spontaneous eye opening and limb lift has been earlier achieved in desflurane than sevoflurane.9 Our findings were also consistent with above study. Jadhav et al studied recovery parameters in both the agents in 80 patients. In their study time to eye opening was achieved earlier in desflurane than sevoflurane. And overall early postoperative recovery is achieved earlier with desflurane than sevoflurane. They used Fast track criteria for discharge from PACU.10 Kotwani et al found out that recovery is achieved earlier in desflurane compared to sevoflurane. They used steward criteria for discharged from PACU. Our findings were consistent with this literature.6 Study by Nathanson et al suggested that there in early recovery period desflurane has a faster recovery profile than sevoflurane. But overall recovery and readiness to home discharge is same for both the agents. Our study result was consistent with early recovery parameter.7 Postoperative complications were statistically analysed by using chi-square test in which result came nonsignificant for all the parameters p>0.05. Study by Nathanson et al suggested that postoperative side effects were similar in both the groups.7 Study by Jadhav et al also suggested that there was no significant difference in postoperative complications in both the groups.10 Study by Jindal et al suggested that there was no difference between complications between study drug groups.5 Our results were consistent with above studies. CONCLUSION Desflurane and sevoflurane does not differ in intraoperative and postoperative hemodynamic parameters, and postoperative adverse effects, however early recovery is achieved with desflurane. Desflurane is better choice in ambulatory laparoscopic gynaecological surgeries.
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