European Journal of Cardiovascular Medicine

Microlaryngeal surgery is a stressful short surgical procedure for diagnosis and treatment of airway disorders, which produces an intense cardiovascular stimulation during suspension laryngoscopy. [1] The need for attenuation of cardiovascular responses and as well as rapid emergence represent a dynamic clinical challenge for anaesthesiologists. [2] Various anaesthetic drugs and a number of alternative anaesthetic techniques have been tried with varying results. [3] The use of intravenous anaesthesia with propofol during microlaryngeal surgery is in widespread clinical practice due to its rapidity and quality of awakening. [4]

It has been successfully used as an alternative to propofol for various day care surgeries. [5] The study compared propofol and etomidate as hypnotics in microlaryngeal surgery combined with jet ventilation. They observed more stable anaesthesia and better recovery with propofol group than etomidate group. [6]

The study compared propofol and methohexital for total intravenous anaesthesia in microlaryngeal surgery. They observed cardiovascular stability with propofol than

methohexitone in microlaryngeal surgery. Another study shown that sevoflurane and remifentanil effectively maintained cardiovascular stability than sevoflurane and alfentanil in patients undergoing microlaryngeal surgery. [7]

The compared hemodynamic response and recovery in patients undergoing microlaryngeal surgery by using bispectral index monitoring. They observed better cardiovascular stability in sevoflurane group than propofol group in patients undergoing microlaryngeal surgery. Recovery was similar in both the groups. [8]

BIS MONITOR was developed by Aspect Medical Systems (Newton, MA). The Bispectral Index (BIS Index) offers the anaesthesia professional a direct and accurate method for continuous brain status monitoring throughout the course of anaesthetic or sedative administration. [9]

Depth of anaesthesia monitoring may reduce the incidence of awareness during anaesthesia, facilitate optimum usage of the amount of anaesthetic used and hasten emergence and recovery. Studies have been conducted by some authors without using BIS to maintain depth of anaesthesia. Few studies used BIS for maintaining depth of anaesthesia but they were not compared the complications. [10]

Present study is designed to compare the effects of sevoflurane and propofol with regard to hemodynamic response, recovery and complications in patients undergoing microlaryngeal surgery by using bispectral index (BIS) with a target of 40- 60 to achieve adequate depth of anaesthesia. [11]

AIM

Comparative study of sevoflurane and propofol on the hemodynamic response, and complications in patients undergoing microlaryngeal surgery by using Bispectral index monitoring.

This is a prospective study conducted in patients undergoing microlaryngeal surgery in the department of anesthesiology at Subbaiah Institute of Medical Sciences and Research Centre, Shivamogga. A total of 60 adult daycare patients belonging to the American Society of Anaesthesiologist grade I or II were included in the study. Patients were divided into two groups named as propofol group (group P) and sevoflurane group (group s) of 30 each by computer randomization tables.

Patients aged 18 to 60 years of ASA grade I and II posted for microlaryngeal surgery under general anaesthesia were included in the study.

Patients age below 18 years and above 60 years, of ASA grade III and IV with morbid obesity, Difficult airway, tracheostomy in situ, pregnant or breast-feeding women, significant cardiopulmonary, respiratory, hepatic, renal, endocrinal, neurological, psychiatric and metabolic diseases, using central nervous system depressants and sedatives with allergy to any drug are excluded from the study.

GROUP S:

Patients are randomly divided into two groups named as propofol group and sevoflurane group. Each group contains 30 patients.

GROUP P:

This group received propofol for induction and maintenance of anesthesia along with N2O-O2 mixture.

GROUP S:

This group received sevoflurane and N2O-O2 mixture for induction and maintenance of anaesthesia.

In group P Anaesthetic induction was carried out with propofol in 20 mg increments every 5 seconds till the BIS value reached 60 and maintained with propofol infusion at the rate of 200 µg/kg/min adjusted in the steps of 25µg/kg/min to maintain the BIS levels between 40 and 60.

In GROUP S anaesthesia was induced with sevoflurane with 60% nitrous oxide in 40% oxygen with a total gas flow of 6 L/min.

Sevoflurane was started at 5% then increased gradually upto 8% till BIS reached to 60. For maintenance of anaesthesia 4% sevoflurane was given with 60% N2O in oxygen and adjusted in the steps of 0.4% to maintain BIS value of 40-60.

The administration of sevoflurane and propofol was discontinued at the end of surgery. The patient was extubated, when patient was conscious and breathing adequately. The duration of surgery, emergence time (time from removal of operating laryngoscope to BIS 80) and the time to extubation were recorded. Patients were observed in the recovery room by an investigator who was blinded to the anaesthesia technique used. The hemodynamic parameters, respiratory rate, and oxygen saturation were recorded at every 10 min intervals till complete recovery.

STATISTICAL ANALYSIS

Data collected was entered in the Microsoft excel and later transferred into statistical package for social sciences (SPSS version 17.0) for analysis. Parametric data was represented in means and standard deviations and non-parametric data was expressed in proportions. Statistical tests like independent sample T test, standard error of difference between proportions were used. P value less than 0.05 is considered statistically significant.

Table 1: Mean age distribution of patients among Propofol and Sevoflurane groups

The mean age of Propofol group was 36±8 years and the mean age in sevoflurane group was 39±7 years. There was no statistical significance of mean ages between two groups.

         Table 2: Mean Weight (Kg) distribution of patients among Propofol and Sevoflurane groups

The mean weight of Propofol group was 63±3 Kgs and the mean weight in sevoflurane group was 63±3 Kgs. There was no statistically significant in relation to mean weight between two groups.

        Table 3: Comparison of Mean Heart rate (beats per minute) among Propofol and Sevoflurane groups

Heart rate before and after premedication in Sevoflurane group and Propofol group was nearly equal. There was decrease in heart rate following induction with both propofol (71.63 ± 6.49) which is statistically significant than sevoflurane (76± 2.99). There is good control of Heart rate after intubation in Sevoflurane group when compared to Propofol group. Which was statistically significant (p<0.001).

                   Table 4: comparison of Mean Heart rate (beats per minute) among Propofol and Sevoflurane groups

There was decrease in Heart rate at all the time intervals in Sevoflurane group when compared to Propofol group which was statistically significant (p<0.001) except at 30 min where the heart rate in Sevoflurane group similar to the Propofol group.

           Table 5: Comparison of Mean arterial pressure (mm Hg) among Propofol and Sevoflurane groups

The Mean arterial pressure before and after premedication in Sevoflurane group and Propofol group is nearly similar. There is decrease in Mean arterial pressure after induction in Sevoflurane group when compared to Propofol group which is statistically significant (P < 0.05).

               Table 6: comparison of Mean arterial pressure (mm Hg) among Propofol and Sevoflurane groups

There is decrease in Mean arterial pressure at 3min , 5min ,15 min , 20 min and 25 min time intervals in Sevoflurane group which is statically significant ( P < 0.05 ) when compared to Propofol group except at 10 min and 30 min where the mean arterial pressure in Propofol group similar to the sevoflurane group.

Table 7: Comparison of emergence time, extubation time and recovery time between Propofol and Sevoflurane groups

There is no significant difference between emergence time and extubation time between the Propofol and sevoflurane groups. The recovery is faster in Sevoflurane group when compared to Propofol group which is statistically significant (P < 0.05).

TABLE 8: Complications among Sevoflurane and Propofol groups

Hypotension and bradycardia is observed more common in Propofol group when compared to sevoflurane group but it was not statistically significant. Post-Operative nausea and vomiting observed in 6 patients in sevoflurane group (20 %) is statistically significant when compared to propofol group.

In the present study the mean arterial pressure during induction of anaesthesia with propofol was 80.1 ± 7.15 mm of Hg which was lower than sevoflurane group 84 ± 12.54 mm of Hg. This fall of mean arterial pressure may be due to its vasodilatory action of propofol. In a study done by Smith et al shown that mean arterial pressure after induction of anaesthsia with propofol (71 ±11) mmHg was lower than sevoflurane (80 ± 14). [12]

In the present study sevoflurane group is associated with less hypotension compared to propofol group and there was good control of mean arterial pressure after intubation in

sevoflurane group compared to propofol group which was stastically significant (P value < 0.05). Thwaites A et al in their study maintenance was smother with sevoflurane and was associated with less hypotension than propofol. [13] Watson KR et al in their study found that cardio vascular stability was good and comparable in both sevoflurane group and propofol groups. [14]

In the present study the mean recovery time with sevoflurane is 13.3 ±1.368 minutes compared to that of propofol group which is 14 ± 1.232 minutes, which is stastically significant (P value < 0.05 ). The Faster recovery by using sevoflurane is due to its low blood gas solubility, resulting in low concentration of sevoflurane dissolved in the blood. After stoppage of sevoflurane, the alveolar concentration rapidly comes down as less amount of it diffuses into the alveoli from the blood, resulting in faster recovery.

Fredman B et al in their study shown that recovery time was similar in sevoflurane and propofol groups. [15] Thwaites A et al in their study shown that emergence from anaesthesia indused with sevoflurane occurred significantly earlier compared with propofol. [16] Dajun Song et al in   their study shown that recovery time was faster in desflurane and sevoflurane group than propofol. [17] Watson KR et al in their study found that recovery time was faster in sevoflurane group compared to propofol group which is stastically significant (P value < 0.05). [14]

 Peduto VA 2000 in their study compared the maintenance and recovery characteristics of sevoflurane and propofol in day care patients undergoing elective surgery. [18] It was observed that significantly shorter times to extubation and emergence in sevoflurane group. Sevoflurane group shown faster emergence and recovery than propofol plus fentanyl group.

Sevoflurane is a better agent compared to propofol, for micro laryngeal surgeries due to stable hemodynamic properties and faster recovery. Post-operative nausea and vomiting is less in patients receiving Propofol than Sevoflurane. In the present study pain assessment and cost analysis are not done and it can be improved by taking these entities in future studies.

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