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Anesthetic Gases in Cardiac Surgery, A Systemic Review

Isoflurane, sevoflurane, and desflurane are volatile anesthetic agents used to induce and maintain general anesthesia. In cardiac surgery, inhaled anesthetics have an additional use case

Isoflurane, sevoflurane, and desflurane are volatile anesthetic agents used to induce and maintain general anesthesia. In cardiac surgery, inhaled anesthetics have an additional use case in providing strong cardioprotective properties during myocardial ischemia. The use of volatile agents at a minimum alveolar concentration (MAC) of 0.5 to 2.0 during cardiac surgery results in fewer individuals needing inotropic support, reduced incidence of myocardial injury, and lower mortality than intravenous anesthesia. Thus, these drugs have been used for anesthesia maintenance in cardiac surgical patients. The different available anesthetic agents, their history, current uses, and common side effects will be discussed in this article, particularly about isoflurane, sevoflurane, desflurane, and propofol.


Fluorinated hydrocarbons first came to light in 1946 for their anesthetic properties, with fluroxene, halothane, and methoxyflurane amongst the first agents to be used clinically. These products, however, had various downsides, including their adverse effect profile, metabolism, and cardiovascular properties. Since these early beginnings, several new fluorinated compounds have been discovered via various methods, including isoflurane, sevoflurane, and desflurane, all of which are used commonly in practice today.


One of the advancements within the new generations of inhaled anesthetics relates to their solubility. Newer inhaled anesthetics, such as desflurane and sevoflurane, are less soluble than older drugs, as defined by their partition coefficients and MAC. MAC indirectly correlates with lipid solubility. Isoflurane, sevoflurane, and desflurane have MACs of 1.6, 1.7, and 1.3, respectively, compared to halothane’s MAC of 1.9. A lower MAC yields a less soluble drug, making products such as isoflurane, sevoflurane, and desflurane better for quicker recovery and early discharge post-op.
All three newer inhaled agents are proven to be safe and effective in maintaining anesthesia and providing cardioprotection. There are few within-class efficacy comparisons amongst different inhaled anesthetics, but existing studies indicate minimal differences. Sevoflurane, for example, has been found to be non-inferior to isoflurane on a composite outcome that included mortality and prolonged ICU stay. It also was not superior to any other of the clinically relevant outcomes.
However, the inhaled agents do differ in their potency, side effect profile, and cost. Side effects associated with volatile anesthetics include hepatotoxicity, nephrotoxicity, neurotoxicity, cardiac arrhythmias, nausea, and vomiting. In terms of arrhythmias, for example, tachycardia typically occurs at MACs of 0.25, 1.0, and 1.5 for isoflurane, desflurane, and sevoflurane, respectively. In healthy patients, desflurane, sevoflurane, and isoflurane have also been shown to prolong the QT interval on the electrocardiogram.


As surgical techniques have advanced over the years, so has the availability of anesthetic agents. One related advancement involves the use of intravenous (IV) anesthesia with propofol instead of inhaled anesthetics. Inhaled anesthetics are also often used together with IV anesthetic agents such as propofol. The literature demonstrates mixed results in evaluating the differences in recovery parameters between desflurane, isoflurane, isoflurane, isoflurane, and propofol. One study demonstrated a statistically significant but slight difference in early recovery rates amongst agents. Early recovery, defined as eye-opening and obeying commands, was only slightly quicker (less than five minutes) when using desflurane and sevoflurane than isoflurane and propofol. The clinical relevance of such findings, however, is likely minimal. Additional literature evaluating clinical outcomes amongst coronary-artery bypass grafting (CABG) patients demonstrated that volatile anesthetics did not significantly reduce death compared to intravenous anesthesia. Bonanni et al., however, indicate that volatile anesthetics were superior to propofol in patients receiving cardiac surgery with a cardiopulmonary bypass with regards to long-term mortality.


In terms of postoperative complications, propofol tends to be more favorable. Isoflurane, desflurane, and sevoflurane all demonstrate increased incidences of nausea and emesis. In studies, postoperative nausea (PON) and postoperative vomiting (POV) were significantly higher with desflurane, sevoflurane, and isoflurane. When comparing the incidence of PON, the inhaled anesthetics and propofol agents had an incidence of 25.8 percent and 14.1 percent, respectively. Regarding POV, the incidence was 16.6 percent and 5.1 percent, respectively. The literature also indicates that pain scores after extubation decreased with propofol versus inhalation agents. Pain, POV, and PON are all determinants of overall patient dissatisfaction, indicating that propofol can play a role in improving early patient well-being regarding pain, nausea, and vomiting.
Additional side effect considerations with anesthetics include headache, in which propofol has been shown to have a lesser incidence than isoflurane. Isoflurane can also cause potentially significant tachycardia compared with other anesthetics, while desflurane has been associated with airway irritation and a pungent odor.


Overall, anesthetic gases offer cardioprotection during cardiac surgery, making them essential for clinical practice. These agents vary in solubility and side effect profile, but efficacy findings are mixed among the different options. Propofol is an intravenous option with a lower incidence of postoperative complications, such as nausea and vomiting.

Read More:

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