Propofol Isoflurane

Story DA, Poustie S, Liu G, McNicol PL. Changes in plasma creatinine concentration after cardiac anesthesia with isoflurane, propofol, or sevoflurane a randomized clinical trial. Anesthesiology 2001 95(4) 842-8. 

Hypnotics. Common hypnotics are thiopental, propofol, midazolam, etomidate, ketamine and inhaled anesthetics. The incidence of hypersensitivity reactions with thiopental is rare. Recently, thiopental was involved in less than 1% of allergic reactions in France [9]. Ever since Cremophor EL, used as a solvent for some non-barbiturate hypnotics, has been avoided, many previously reported hypersensitivity reactions have disappeared. In the last French surveys, reactions to propofol accounted for less than 2.5% of allergic reactions, and reactions to midazolam, etomidate or ketamine appear to be really rare [9]. Finally, no immune-mediated immediate hypersensitivity reaction involving isoflurane, desflurane or sevoflurane has been reported despite their wide use. 

General anesthesia - Remifentanil is not recommended as the sole agent in general anesthesia because loss of consciousness cannot be assured and because of a high incidence of apnea, muscle rigidity, and tachycardia. Remifentanil is synergistic with other anesthetics and doses of thiopental, propofol, isoflurane, and midazolam have been... 

Unlike isoflurane, desflurane may stimulate the sympathetic nervous system at concentrations above 1 MAC. Sudden and unexpected increases in arterial blood pressure and heart rate have been reported in some patients, accompanied by increases in plasma catecholamine and vasopressin concentrations and increased plasma renin activity. These pressor effects may increase morbidity or mortality in susceptible patients. The mechanism of sympathetic activation is unclear but does not appear to be baroreceptor-mediated. Clonidine, esmolol, fentanyl and propofol partially block the response but lignocaine (lignocaine) is ineffective. 

Gupta A et al Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane A systematic review. Anesth Analg 2004 98 632. [PMID 14980911]... 

Kahveci et al. (13) compared the cerebral protective effects of two known protective anesthetics, isoflurane and propofol, in combination with hypothermia (33-34°C) after traumatic brain injury (TBI). In that study, the authors found that propofol anesthesia plus hypothermia following TBI was better than the isoflurane-hypothermia combination because it reduced intracranial pressure and increased cerebral perfusion pressure under those conditions. 

Kahveci F. S., Kahveci N., Alkan T., Goren B., Korfali E., and Ozluk K. (2001) Propofol versus isoflurane anesthesia under hypothermic conditions effects on intracranial pressure and local cerebral blood flow after diffuse traumatic brain injury in the rat. Surg. Neurol. 56, 206-214. 

In 113 patients undergoing general anesthesia, intravenous midazolam 15 mg slowed recovery of the twitch height after vecuronium and atracurium compared with diazepam. The recovery index was not altered (162). However, in another study in 20 patients, midazolam 0.3 mg/kg did not affect the duration of blockade, recovery time, intensity of fasciculations, or adequacy of relaxation for tracheal intubation produced by suxamethonium 1 mg/kg, nor the duration of blockade and adequacy of relaxation for tracheal intubation produced by pancuronium 0.025 mg/kg in incremental doses until 99% depression of muscle-twitch tension was obtained (161). Furthermore, in 60 patients undergoing maintenance anesthesia randomly assigned to one of six regimens (etomidate, fentanyl, midazolam, propofol, thiopental plus nitrous oxide, or isoflurane plus nitrous oxide), midazolam did not alter rocuronium dosage requirements (165). 

Olkkola KT, Tammisto T. Quantifying the interaction of rocuronium (Org 9426) with etomidate, fentanyl, midazolam, propofol, thiopental, and isoflurane using closed-loop... 

Uses. Nitrous oxide is used to maintain surgical anaesthesia in combination with other anaesthetic agents, e.g., isoflurane or propofol, and, if required, muscle relaxants. Entonox provides analgesia for obstetric practice, for emergency management of injuries, and during postoperative physiotherapy. 

A 35-year-old man developed recurrent respiratory depression after being given alfentanil 0.0125 mg/kg for vitreoretinal surgery (5). General anesthesia was induced with a combination of propofol, rocuronium, and alfentanil, subsequent inhalation of isoflurane, and three additional doses of alfentanil (total 0.04 mg/kg over 2 hours). The pulse oxygen saturation fluctuated and was as low as 89% 180 minutes after extubation. 

Both desflurane and sevoflurane significantly increase the neuromuscular blocking effects of rocuronium compared with isoflurane or propofol (20,21). 

In a comparison of sevoflurane and isoflurane anesthesia in 2008 patients there was a 3-4 minute reduction in time to recovery end-points with sevoflurane (19). These differences became larger in anesthetics lasting over 3 hours and were trivial in cases less than 1 hour. Patients aged over 65 years had a 5-minute increase in recovery times after receiving isoflurane. There was no significant difference in the incidence of nausea or vomiting between isoflurane, sevoflurane, and propofol. 

Both desflurane and sevoflurane significantly increase the neuromuscular blocking effects of rocuronium compared with isoflurane or propofol (41,42). The effective doses of rocuronium for 50% depression of single twitch height were 95,120,130, and 150 pg/kg for desflurane, sevoflurane, isoflurane, and propofol respectively. There were no differences in recovery profiles between the four drugs using equieffective doses. Desflurane, sevoflurane, and to a lesser extent isoflurane, also potentiated the neuromuscular blocking effect of cisatracurium by 30% compared with propofol (43,44). 

Ebert TJ, Robinson BJ, Uhrich TD, Mackenthun A, Pichotta PJ. Recovery from sevoflurane anesthesia a comparison to isoflurane and propofol anesthesia. Anesthesiology 1998 89(6) 1524-31. 

An obese 35-year-old diabetic woman developed isoflurane-induced hepatotoxicity (15). She had had four previous halothane anesthetics, the last two of which were associated with jaundice. She made a full recovery and during a subsequent anesthetic received an infusion of propofol. Unfortunately, trifluoroacetic acid antibody titers were not performed. Liver function does not appear to have been severely affected peak alanine transaminase activity was 1410 IU/1. 

Propofol is a short-acting intravenous induction agent, which is dissolved in a mixture of long-chain triglycerides and soya bean emulsion. It is now in general use in daycare anesthesia and is being increasingly used in infusions in intensive care units. Recovery from anesthetic doses compares favorably with that after enflurane and isoflurane (1). 

It has been claimed that propofol produces good recovery after anesthesia. A review of the literature has shown that, for operations that last under 30 minutes, propofol seems to give the best recovery, but for longer operations isoflurane gave better quality recovery (2). 

Total intravenous anesthesia with propofol resulted in a reduced heart rate and a higher frequency of oculocardiac reflex bradycardia than thiopental/isoflurane anesthesia, with a higher sensitivity of children younger than 6 years in all groups (11). 

Convulsions have been reported in two patients with no history of epilepsy after induction of anesthesia with propofol (44). However, in a crossover comparison in 20 epileptic patients undergoing cortical resection, in which the effects on the electrocorticogram of either propofol or thiopental during isoflurane + nitrous oxide anesthesia were studied, propofol caused no greater proconvulsive effect than thiopental, which is used to treat status epilepticus (45). In spite of occasional reports, a true epileptogenic effect of propofol remains to be proven. 

Carpentier JP, Rion O, Petrognani R, Seignot P, Anbert M. Etude comparee du reveil apres entretien de I anesthesie par propofol on isoflurane. Essai de synthese des donnees actueUes. [A comparative study of recovery following maintenance of anesthesia with propofol or isoflurane. An attempt to synthesize current data.] Cah Anesthesiol 1993 41(4) 327-30. 

Davis PJ, Lerman J, Suresh S, McGowan EX, Cote CJ, Landsman I, Henson LG. A randomized multicenter study of remifentanil compared with alfentanil, isoflurane, or propofol in anesthetized pediatric patients undergoing elective strabismus surgery. Anesth Analg 1997 84(5) 982-9. 

Plasma activity of alpha-glutathione 5-transferase activity (aGT) is a more sensitive and specific marker of hepatocellular injury than transaminase activity and it correlates better with hepatic histology. Anesthesia with halothane leads to transiently raised aGT activity, but propofol and isoflurane do not. In a randomized study of plasma aGT activity during and after low-flow anesthesia with sevoflurane or isoflurane, there were no significant differences in aGT activities between the two groups during or after anesthesia (34). 

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