Desflurane is a volatile halogenated ether used as an inhalational general anesthetic. It is commonly employed in surgeries requiring general anesthesia, such as abdominal, orthopedic, and gynecological procedures.

Desflurane is administered via inhalation, typically through a specialized anesthesia delivery system. It induces anesthesia rapidly, and its effects wear off quickly once administration is stopped, allowing for a faster recovery compared to some other anesthetic agents.

Desflurane (Suprane) is an inhalational anesthetic agent used in the maintenance of general anesthesia.

Indications of Desflurane (Suprane):

• Anesthesia:
  • It is used for induction of anesthesia in adults and maintenance of anesthesia in adults and pediatric patients for inpatient and outpatient surgery.

Note:

• Due to its irritant properties and unpleasant odor which may cause coughing, breath-holding, laryngospasm, oxygen desaturation, increased secretions, hypertension, and tachycardia, it is not suitable for induction of general anesthesia in adults.
• Due to the risk of moderate to severe airway adverse effects, desflurane use for induction of anesthesia in non-intubated pediatric patients is contraindicated.
• Desflurane is indicated for the maintenance of anesthesia in infants and children after induction of anesthesia with an alternate agent and tracheal intubation.

Desflurane dose in adults:

Note: Dosage must be individualized based on patient response.

Dose in the Induction of anesthesia:

• When starting anesthesia with desflurane, the usual dose for induction is to begin with an inhaled concentration of 3%.
• This concentration is then increased gradually by adding 0.5% to 1% more every 2 to 3 breaths until the desired level of anesthesia is reached, which typically falls between 4% and 11%.
• However, it's possible to safely administer concentrations higher than 12% during induction, although this might require adjusting the levels of nitrous oxide or air being delivered alongside desflurane.

Desflurane (Suprane) Dose in the maintenance of anesthesia:

• During the maintenance phase of anesthesia, desflurane is typically administered at inhaled concentrations ranging from 2.5% to 8.5%, either alone or in combination with nitrous oxide.
• The effectiveness of desflurane varies by age, with the minimum alveolar concentration (MAC) needed to prevent a response to surgical incision decreasing as age increases.
• For instance, in adults, the concentration required to induce amnesia and loss of awareness (known as MAC-awake) is approximately 2.4%.
• However, to maintain adequate surgical anesthesia, concentrations between 2.5% and 8.5% are generally used.
• The vaporizer used for desflurane is heated to ensure a constant concentration due to its high vapor pressure.
• It's important to note that when desflurane is used concurrently with benzodiazepines, nitrous oxide, or opioids, the dose may need to be adjusted downwards.

Desflurane dose in children:

Note: Dosage must be individualized based on patient response.

Desflurane (Suprane) Dose in the maintenance of anesthesia:

• During the maintenance phase of anesthesia in children, desflurane is typically administered at inhaled concentrations ranging from 5.2% to 10%, with or without nitrous oxide.
• The required concentration varies with the child's age, with surgical levels of anesthesia generally maintained between 5.2% and 10%.
• The minimum alveolar concentration (MAC), which represents the concentration at which 50% of patients do not respond to surgical incision, also varies with age.
• For instance, in infants aged 9 months, the MAC with 100% oxygen is 10%, while with a mixture of 60% nitrous oxide and 40% oxygen, it's 7.5%.
• It's important to note that concurrent use with benzodiazepines, nitrous oxide, or opioids may necessitate adjusting the desflurane dose.
• Additionally, due to desflurane's higher vapor pressure, its vaporizer is heated to ensure a constant concentration.

Desflurane (Suprane) Pregnancy Risk Category: B

• Based on research with animals, using general anesthesia medications like desflurane that affect certain receptors in the brain might have consequences on brain development, especially in human fetuses during the third trimester of pregnancy.
• It's essential to carefully consider the benefits and risks of using desflurane in pregnant women, especially for surgeries lasting more than 3 hours.
• While desflurane has been used in obstetric anesthesia, other medications are more commonly preferred.
• It's important to minimize the exposure of pregnant women to desflurane because it can relax the uterus and depress fetal activity.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women should not be denied necessary surgeries or procedures, regardless of the trimester, but non-urgent surgeries should ideally be scheduled during the second trimester, and elective procedures should be postponed until after delivery.

Desflurane use during breastfeeding:

• It's uncertain whether desflurane passes into breast milk.
• The manufacturer suggests caution when giving desflurane to breastfeeding mothers.
• However, considering its pharmacokinetic properties, using desflurane for maintaining anesthesia in breastfeeding women is deemed acceptable.
• The Academy of Breastfeeding Medicine recommends delaying elective surgery until the breastfeeding child is older and breastfeeding is well established.
• Before surgery, if possible, milk should be expressed.
• Typically, breastfeeding can resume or milk can be expressed once the mother is awake and in recovery, especially for healthy, full-term infants.
• For more vulnerable children, milk can be stored for later use when the risk is lower.

Desflurane (Suprane) Dose adjustment in renal disease:

No dosage adjustment is necessary.   

Desflurane (Suprane) Dose adjustment in liver disease:

No dosage adjustment is necessary.   

Common Side Effects of Desflurane (Suprane):

• Gastrointestinal:
  • Nausea
  • Vomiting
• Respiratory:
  • Cough
  • Breath-holding
  • Apnea

Rare Side Effects of Desflurane (Suprane):

• Cardiovascular:
  • Oxygen saturation decreased
  • Bradycardia
  • Hypertension (including malignant hypertension)
  • Nodal arrhythmia
  • Shivering
  • Tachycardia
• Central nervous system:
  • Headache
• Gastrointestinal:
  • Sialorrhea
• Ophthalmic:
  • Conjunctivitis
• Neuromuscular & skeletal:
  • Laryngospasm
• Respiratory:
  • Increased bronchial secretions
  • Pharyngitis

Contraindications to Desflurane (Suprane):

• Desflurane is not recommended for individuals with hypersensitivity to desflurane, other similar agents, or any components of its formulation.
• It should also be avoided in patients with a known or suspected genetic predisposition to malignant hyperthermia, as well as those for whom general anesthesia is not advised.
• Desflurane is contraindicated for pediatric patients during anesthesia induction.
• Additionally, individuals with a history of moderate to severe liver problems following anesthesia with desflurane or similar agents should avoid its use unless specifically recommended by a healthcare professional.
• In Canadian labeling, there are additional contraindications not listed in US labeling. These include a history of hepatitis due to a halogenated inhalational anesthetic or individuals who have experienced liver dysfunction, jaundice, unexplained fever, leukocytosis, or eosinophilia after previous administration of halogenated anesthetics. These individuals should also avoid desflurane.

Warnings and precautions

Reduced blood flow

• Desflurane can potentially lead to a decrease in blood flow to the liver and/or kidneys.
• This reduction in blood flow may affect the normal functioning of these organs, including their ability to filter toxins and metabolize substances.
• Therefore, caution is necessary when using desflurane, especially in patients with pre-existing liver or kidney conditions, as it may exacerbate their condition.
• Monitoring of liver and kidney function is typically performed during anesthesia to ensure patient safety.

Hepatitis

• Desflurane has the potential to trigger hepatitis, an inflammation of the liver, particularly in patients who have been sensitized by previous exposure to halogenated anesthetics.
• Sensitization refers to the development of an increased sensitivity or allergic reaction after prior exposure to a particular substance.
• Therefore, individuals with a history of hepatitis linked to previous use of halogenated anesthetics should exercise caution when considering desflurane for anesthesia.

Hyperkalemia:

• The use of inhaled anesthetics like desflurane has been linked to rare instances of perioperative hyperkalemia, a condition characterized by high levels of potassium in the blood, particularly in pediatric patients.
• Some reported cases involved the simultaneous use of succinylcholine, a muscle relaxant, but not all.
• Patients with underlying neuromuscular diseases, such as Duchenne muscular dystrophy, are at an increased risk of hyperkalemia.
• Additional abnormalities may include elevated levels of creatine kinase (CK) and myoglobinuria.
• It's crucial to closely monitor patients for any signs of arrhythmias and promptly identify and treat hyperkalemia if it occurs.

Increased intracranial pressure

• Desflurane can potentially dilate the blood vessels in the brain, which might lead to an increase in intracranial pressure under certain conditions.
• For patients with intracranial space-occupying lesions, it's recommended to administer desflurane at a maximum concentration of 0.8 MAC (minimum alveolar concentration) along with a barbiturate induction and hyperventilation before cranial decompression.
• It's crucial to maintain cerebral perfusion pressure to ensure adequate blood flow to the brain while managing intracranial pressure.
• This approach helps mitigate the risk of exacerbating intracranial pressure-related complications during anesthesia.

Malignant hyperthermia

• Desflurane use can potentially trigger malignant hyperthermia (MH), a rare but life-threatening condition characterized by a rapid rise in body temperature and muscle rigidity.
• In some reported cases, MH associated with desflurane has been fatal.
• Therefore, desflurane is contraindicated in patients who are susceptible to MH.
• It's essential for healthcare providers to be vigilant and promptly recognize any signs or symptoms of MH during anesthesia, such as rapid increase in body temperature, muscle rigidity, and metabolic acidosis, to initiate appropriate treatment and prevent adverse outcomes.

Extension of QT

• There have been reported cases of QT prolongation, a heart rhythm disorder, associated with inhaled anesthetic agents like desflurane.
• In some instances, this condition has led to torsade de pointes, a potentially fatal heart rhythm abnormality.
• It's important to exercise caution when administering desflurane to patients who are at risk of QT prolongation.
• This includes individuals taking medications known to prolong the QT interval, such as certain antiarrhythmic drugs (class Ia and III), elderly patients, and those with congenital QT prolongation.

Respiratory depression

• Desflurane can cause dose-dependent respiratory depression, meaning it can slow down breathing, especially when given in higher doses.
• It can also blunt the body's natural response to low oxygen levels and high carbon dioxide levels, which are important signals for regulating breathing.
• Desflurane may decrease the body's ability to constrict blood vessels in the lungs when oxygen levels are low, potentially leading to increased mixing of oxygen-poor blood with oxygen-rich blood.
• Additionally, in certain circumstances, desflurane exposure can lead to elevated levels of carbon monoxide and carboxyhemoglobin when there is a dry carbon dioxide absorbent in the anesthesia machine's breathing system.
• To prevent this, it's essential to maintain fresh absorbent according to the manufacturer's guidelines, regardless of the color of the indicator.
• This ensures the safe removal of carbon dioxide during anesthesia.

Cardiovascular disease

• Desflurane should not be used alone to induce anesthesia in patients with coronary artery disease (CAD) or those who should avoid increases in heart rate or blood pressure.
• When the inspired concentration of desflurane abruptly increases beyond a certain threshold (greater than 1 minimum alveolar concentration, MAC), there can be a transient rise in blood pressure and heart rate due to elevated levels of plasma catecholamines.
• This acute increase in desflurane concentration can lead to heightened sympathetic nervous system activity, which typically lasts for 2 to 4 minutes.
• However, this effect can be mitigated by using concurrent medications such as nitrous oxide, opioids, beta-blockers, and alpha-2 agonists.
• Desflurane's hypotensive effect, caused by peripheral vasodilation, becomes more pronounced as anesthesia deepens.
• Additionally, according to a scientific statement from the American Heart Association, desflurane has been identified as an agent that might worsen underlying myocardial dysfunction, indicating a significant concern.

Hepatic disease

• In patients with hepatic disease such as cirrhosis, viral hepatitis, or other liver conditions, caution should be exercised when considering the use of desflurane due to the risk of hepatitis associated with halogenated anesthetics.
• There have been reports of liver function disruption, jaundice, and even fatal liver necrosis, which may suggest hypersensitivity reactions.
• It's advisable to contemplate using an alternative anesthetic rather than a halogenated one in such cases to minimize the potential risks to the liver.

Desflurane: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy).
Alcohol (Ethyl)	CNS Depressants can increase the CNS depressant effects of Alcohol (Ethyl).
Alfuzosin	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Alizapride	CNS Depressants may increase the CNS depressant effects.
Antipsychotic Agents, Second Generation (Atypical)	Blood Pressure Lowering Agents can increase the hypotensive effects of Antipsychotic Agents (Second Gen [Atypical]).
Barbiturates	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Benperidol	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Blood Pressure Lowering Agents	May enhance the hypotensive effect of HypotensionAssociated Agents.
Brexanolone	CNS Depressants can increase the CNS depressant effects of Brexanolone.
Brimonidine (Topical)	CNS Depressants may increase the CNS depressant effects.
Brimonidine (Topical)	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Bromopride	CNS Depressants may increase the CNS depressant effects.
Cannabidiol	CNS Depressants may increase the CNS depressant effects.
Cannabis	CNS Depressants may increase the CNS depressant effects.
Chlorphenesin Carbamate	CNS Depressants may have an adverse/toxic effect that can be exacerbated by them.
CNS Depressants	Can increase the toxic/adverse effects of CNS Depressants.
Diazoxide	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Dimethindene (Topical).	CNS Depressants may increase the CNS depressant effects.
Doxylamine	CNS Depressants may have a greater CNS depressant effect if taken with other CNS Depressants. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with other CNS depressants is not recommended.
Dronabinol	CNS Depressants may increase the CNS depressant effects.
DULoxetine	DULoxetine may increase hypotensive effects by lowering blood pressure.
EPINEPHrine (Nasal)	Inhalational anesthetics can increase the arrhythmogenic effects of EPINEPHrine.
EPINEPHrine (Oral Inhalation)	Inhalational Anesthesia may increase the arrhythmogenic effects of EPINEPHrine (Oral Inhalation).
Esketamine	CNS Depressants may increase the CNS depressant effects.
Fenoterol	Inhalational anesthetics can increase the arrhythmogenic effects of Fenoterol.
Formoterol	Formoterol's arrhythmogenic effects may be enhanced by inhalational anesthetics.
Haloperidol	QT-prolonging agents (Indeterminate risk - Caution), may increase the QTcprolonging effects of Haloperidol.
Herbs (Hypotensive properties)	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
HydrOXYzine	CNS Depressants may increase the CNS depressant effects.
Hypotension-Associated Agents	Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents.
Kava Kava	CNS Depressants may have an adverse/toxic effect that can be exacerbated by them.
Levodopa-Containing Products	Blood Pressure Lowering Agents can increase the hypotensive effects of Levodopa -Containing Products.
Lofexidine	CNS Depressants may have a greater depressant effect on the brain. Management: Separate drug interaction monographs are available for drugs listed as an exception to this monograph.
Lormetazepam	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Magnesium Sulfate	CNS Depressants may increase the CNS depressant effects.
MetyroSINE	MetyroSINE may have a sedative effect that can be enhanced by CNS depressants.
Minocycline	CNS Depressants may increase the CNS depressant effects.
Mirtazapine	CNS Depressants can increase the CNS depressant effects of Mirtazapine.
Molsidomine	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nabilone	CNS Depressants may increase the CNS depressant effects.
Naftopidil	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Neuromuscular-Blocking Agents (Nondepolarizing)	Inhalational Anesthetics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing).
Nicergoline	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nicorandil	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nitroprusside	The hypotensive effects of Nitroprusside may be enhanced by blood pressure lowering agents.
Pentoxifylline	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Pholcodine	Pholcodine may increase hypotensive effects by lowering blood pressure.
Phosphodiesterase 5 Inhibitors	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Piribedil	CNS Depressants could increase the CNS depressant effects of Piribedil.
Pramipexole	Pramipexole may have a greater sedative effect if it is combined with CNS depressants.
Prostacyclin Analogues	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Agents that prolong QT (Highest risk)	QT-prolonging agents (Indeterminate risk - Caution), may increase the QTc prolonging effect of QT Prolonging Agents. When using these agents together, be sure to monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Quinagolide	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Ritodrine	This may increase the toxic/adverse effects of Inhalational Anesthetics.
ROPINIRole	CNS Depressants can increase the sedative effects of ROPINIRole.
Rotigotine	CNS Depressants can increase the sedative effects of Rotigotine.
Rufinamide	CNS Depressants may have an adverse/toxic effect that can be exacerbated by this. Particularly, dizziness and sleepiness may be increased.
Selective Serotonin Reuptake inhibitors	CNS Depressants can increase the toxic/adverse effects of Selective Serotonin Resuptake Inhibitors. Particularly, psychomotor impairment could be increased.
Tetrahydrocannabinol	CNS Depressants may increase the CNS depressant effects.
Tetrahydrocannabinol, and Cannabidiol	CNS Depressants may increase the CNS depressant effects.
Trimeprazine	CNS Depressants may increase the CNS depressant effects.
Risk Factor D (Consider therapy modifications)
Amifostine	Amifostine's hypotensive effects may be enhanced by blood pressure lowering agents. Treatment: Blood pressure lowering drugs should be stopped 24 hours before amifostine administration. Amifostine should be avoided if blood pressure lowering medication cannot be withheld.
Bambuterol	May increase the arrhythmogenic effects of Inhalational Anesthesthetics. Management: Some labels advise against halothane use; others suggest that you separate the administration for at least 6 hours. Other bambuterol labels don't mention any possible interactions.
Blonanserin	CNS Depressants can increase the CNS depressant effects of Blonanserin.
Buprenorphine	CNS Depressants can increase the CNS depressant effects of buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Buprenorphine patches (Butrans) should be initiated at 5 mg/hr for adults. This is when it is combined with other CNS depression drugs.
Chlormethiazole	CNS Depressants may increase the CNS depressant effects. Monitoring: Look out for signs of CNS depression. If a combination of chlormethiazole and other drugs is required, a reduced dose should be used.
Droperidol	CNS Depressants may increase the CNS depressant effects. Management: Droperidol and other CNS agents, such as opioids, may be reduced or used in combination with droperidol. Separate drug interaction monographs provide more detail on exceptions to this monograph.
EPINEPHrine (Systemic)	Systemic may have an arrhythmogenic effect from inhalational anesthetics. Patients who are currently receiving or have received inhalational anesthetics should be administered epinephrine cautiously. Monitor for cardiac arrhythmias and use lower doses than usual.
Flunitrazepam	CNS Depressants can increase the CNS depressant effects of Flunitrazepam.
HYDROcodone	CNS Depressants can increase the CNS depressant effects of HYDROcodone. When possible, avoid concomitant use with hydrocodone, benzodiazepines, or other CNS depressionants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Methotrimeprazine	Methotrimeprazine may have a higher CNS depressant activity than CNS Depressants. Methotrimeprazine can increase the CNS depressant effects of CNS Depressants. Management: Lower the adult dose of CNS Depressants by 50% and start concomitant methotrimeprazine treatment. After clinically proven efficacy of methotrimeprazine, further CNS depressant dose adjustments should only be made.
Obinutuzumab	This may increase the hypotensive effects of Blood Pressure Lowering Agents. Management: You may temporarily withhold blood pressure lowering medication beginning 12 hours before obinutuzumab injection and continuing for 1 hour after infusion.
Opioid Agonists	CNS Depressants can increase the CNS depressant effects of Opioid Aggonists. Management: When possible, avoid concomitant use opioid agonists, benzodiazepines, or other CNS depressionants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
OxyCODONE	CNS Depressants can increase OxyCODONE's CNS depressant effects. When possible, avoid the simultaneous use of oxycodone and other CNS depressants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Perampanel	CNS Depressants may have a greater CNS depressant effect. Perampanel and any other CNS depressant drug should be used in combination. Patients who take perampanel together with other drugs that have CNS depressant activity should not engage in complex or high-risk activities until they are familiar with the combination.
Sodium Oxybate	CNS Depressants may have a greater depressant effect if taken in combination. Management: Look for alternatives to the combination use. If you must combine use, reduce the dose of any one or more drugs. It is not recommended to combine sodium oxybate and alcohol, or any sedative hypnotics.
Suvorexant	CNS Depressants can increase the CNS depressant effects of Suvorexant. Management: Suvorexant or any other CNS depressionant can be reduced in doses. Suvorexant should not be taken with alcohol. It is also not recommended to take suvorexant along with any other drugs for insomnia.
Tapentadol	CNS Depressants may increase the CNS depressant effects. Tapentadol, benzodiazepines and other CNS depressants should be avoided when possible. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Zolpidem	CNS Depressants can increase the CNS depressant effects of Zolpidem. Management: For men who also take CNS depressants, reduce the adult Intermezzo brand sublingual Zolpidem dose to 1.75mg. For women, no dose adjustment is advised. Avoid using CNS depressants at night; do not use alcohol.
Risk Factor X (Avoid Combination)
Azelastine (Nasal)	CNS Depressants could increase the CNS depressant effects of Azelastine.
Bromperidol	Bromperidol's hypotensive effects may be enhanced by Blood Pressure Lowering agents. Bromperidol could decrease the hypotensive effects of Blood Pressure Lowering agents.
Bromperidol	CNS Depressants may increase the CNS depressant effects.
Dexmethylphenidate	May increase the hypertensive effects of Inhalational Anesthestics.
DOPamine	Inhalational Anesthetics can increase the arrhythmogenic effects of DOPamine. Patients receiving halogenated Hydrocarbon Anesthetics should not use dopamine. Monitor for arrhythmia if concomitant treatment is not possible. Propranolol, based on animal data, may reverse ventricular arrhythmia caused by dopamine.
Ephedra	May increase the arrhythmogenic effects of Inhalational Anesthestics.
EPHEDrine (Nasal).	May increase the arrhythmogenic effects of Inhalational Anesthestics.
EPHEDrine (Systemic)	May increase the arrhythmogenic effects of Inhalational Anesthestics.
Isoproterenol	Inhalational anesthetics can increase the arrhythmogenic effects of Isoproterenol.
Metaraminol	Metaraminol's arrhythmogenic effects may be enhanced by inhalational anesthetics.
Methylphenidate	May increase the hypertensive effects of Inhalational Anesthestics.
Norepinephrine	Inhalational anesthetics can increase the arrhythmogenic effects of Norepinephrine.
Orphenadrine	Orphenadrine may be more effective against CNS depression than other drugs.
Oxomemazine	CNS Depressants may increase the CNS depressant effects.
Paraldehyde	Paraldehyde may be enhanced by CNS depressants.
Thalidomide	CNS Depressants can increase Thalidomide's CNS depressant effects.

Monitoring parameters:

• Blood Pressure, Heart Rate, and Rhythm:
  • Monitoring of blood pressure, heart rate, and heart rhythm is essential before and throughout anesthesia to ensure cardiovascular stability and detect any abnormalities promptly.
• Temperature:
  • Monitoring of body temperature helps in assessing the patient's physiological status and detecting any signs of hyperthermia or hypothermia during anesthesia.
• Oxygen Saturation:
  • Continuous monitoring of oxygen saturation ensures adequate oxygen delivery to tissues and early detection of hypoxemia, a condition where there is an insufficient amount of oxygen in the blood.
• End-Tidal CO₂ and Desflurane Concentrations:
  • Monitoring end-tidal CO₂ levels provides information about the patient's ventilation status, while monitoring end-tidal desflurane concentrations helps in controlling the depth of anesthesia and preventing overdose.

Special Considerations for Pediatric Patients

• Adverse Respiratory Symptoms (≤6 years):
  • Pediatric patients, especially those aged 6 years and below, should be closely monitored for any adverse respiratory symptoms during anesthesia, as they may have a limited ability to express discomfort or distress.
• Signs and Symptoms of Airway Narrowing:
  • Children with asthma or recent upper respiratory infections should be carefully observed for signs and symptoms of airway narrowing during anesthesia, as they are at increased risk of experiencing respiratory complications. Early detection allows for prompt intervention to prevent complications.

How to administer Desflurane (Suprane)?

Via Desflurane-Specific Calibrated Heated Vaporizer:

• Desflurane is administered through a specialized vaporizer designed specifically for its use.
• The vaporizer is calibrated to ensure accurate delivery of desflurane concentrations.
• Heating is applied to maintain desflurane in its gaseous state for precise administration during anesthesia.

Mechanism of action of Desflurane (Suprane):

• Desflurane is believed to induce general anesthesia by increasing the activity of inhibitory postsynaptic channels while simultaneously decreasing excitatory synaptic activity, although the exact mechanisms are not fully understood.
• This combination of effects results in the suppression of neural activity, leading to the loss of consciousness and pain sensation during surgery.

Onset of Action

• 1 to 2 minutes:
  • Desflurane typically begins to take effect within 1 to 2 minutes after administration, inducing anesthesia relatively quickly compared to other agents.

Duration

• Emergence Time:
  • The time it takes for a patient to wake up from anesthesia with desflurane depends on the concentration of the drug in their bloodstream at the time it is discontinued.

Metabolism

• Hepatic Metabolism:
  • Desflurane is primarily metabolized in the liver, with only a small fraction (approximately 0.02%) undergoing metabolic transformation to trifluoroacetate and inorganic fluoride.

Excretion

• Exhaled Gases:
  • Desflurane is eliminated from the body primarily through exhalation as part of the exhaled gases during respiration.

International Brands of Desflurane:

• Suprane
• Sulorane

Desflurane Brands in Pakistan:

You can check for availability and prices by clicking the WhatsApp link here: https://wa.me/message/HV6M3JGTA6RJB1

Desflurane is a volatile halogenated ether used as an inhalational general anesthetic. It is commonly employed in surgeries requiring general anesthesia, such as abdominal, orthopedic, and gynecological procedures.

Desflurane is administered via inhalation, typically through a specialized anesthesia delivery system. It induces anesthesia rapidly, and its effects wear off quickly once administration is stopped, allowing for a faster recovery compared to some other anesthetic agents.

Desflurane (Suprane) is an inhalational anesthetic agent used in the maintenance of general anesthesia.

Indications of Desflurane (Suprane):

• Anesthesia:
  • It is used for induction of anesthesia in adults and maintenance of anesthesia in adults and pediatric patients for inpatient and outpatient surgery.

Note:

• Due to its irritant properties and unpleasant odor which may cause coughing, breath-holding, laryngospasm, oxygen desaturation, increased secretions, hypertension, and tachycardia, it is not suitable for induction of general anesthesia in adults.
• Due to the risk of moderate to severe airway adverse effects, desflurane use for induction of anesthesia in non-intubated pediatric patients is contraindicated.
• Desflurane is indicated for the maintenance of anesthesia in infants and children after induction of anesthesia with an alternate agent and tracheal intubation.

Desflurane dose in adults:

Note: Dosage must be individualized based on patient response.

Dose in the Induction of anesthesia:

• When starting anesthesia with desflurane, the usual dose for induction is to begin with an inhaled concentration of 3%.
• This concentration is then increased gradually by adding 0.5% to 1% more every 2 to 3 breaths until the desired level of anesthesia is reached, which typically falls between 4% and 11%.
• However, it's possible to safely administer concentrations higher than 12% during induction, although this might require adjusting the levels of nitrous oxide or air being delivered alongside desflurane.

Desflurane (Suprane) Dose in the maintenance of anesthesia:

• During the maintenance phase of anesthesia, desflurane is typically administered at inhaled concentrations ranging from 2.5% to 8.5%, either alone or in combination with nitrous oxide.
• The effectiveness of desflurane varies by age, with the minimum alveolar concentration (MAC) needed to prevent a response to surgical incision decreasing as age increases.
• For instance, in adults, the concentration required to induce amnesia and loss of awareness (known as MAC-awake) is approximately 2.4%.
• However, to maintain adequate surgical anesthesia, concentrations between 2.5% and 8.5% are generally used.
• The vaporizer used for desflurane is heated to ensure a constant concentration due to its high vapor pressure.
• It's important to note that when desflurane is used concurrently with benzodiazepines, nitrous oxide, or opioids, the dose may need to be adjusted downwards.

Desflurane dose in children:

Note: Dosage must be individualized based on patient response.

Desflurane (Suprane) Dose in the maintenance of anesthesia:

• During the maintenance phase of anesthesia in children, desflurane is typically administered at inhaled concentrations ranging from 5.2% to 10%, with or without nitrous oxide.
• The required concentration varies with the child's age, with surgical levels of anesthesia generally maintained between 5.2% and 10%.
• The minimum alveolar concentration (MAC), which represents the concentration at which 50% of patients do not respond to surgical incision, also varies with age.
• For instance, in infants aged 9 months, the MAC with 100% oxygen is 10%, while with a mixture of 60% nitrous oxide and 40% oxygen, it's 7.5%.
• It's important to note that concurrent use with benzodiazepines, nitrous oxide, or opioids may necessitate adjusting the desflurane dose.
• Additionally, due to desflurane's higher vapor pressure, its vaporizer is heated to ensure a constant concentration.

Desflurane (Suprane) Pregnancy Risk Category: B

• Based on research with animals, using general anesthesia medications like desflurane that affect certain receptors in the brain might have consequences on brain development, especially in human fetuses during the third trimester of pregnancy.
• It's essential to carefully consider the benefits and risks of using desflurane in pregnant women, especially for surgeries lasting more than 3 hours.
• While desflurane has been used in obstetric anesthesia, other medications are more commonly preferred.
• It's important to minimize the exposure of pregnant women to desflurane because it can relax the uterus and depress fetal activity.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women should not be denied necessary surgeries or procedures, regardless of the trimester, but non-urgent surgeries should ideally be scheduled during the second trimester, and elective procedures should be postponed until after delivery.

Desflurane use during breastfeeding:

• It's uncertain whether desflurane passes into breast milk.
• The manufacturer suggests caution when giving desflurane to breastfeeding mothers.
• However, considering its pharmacokinetic properties, using desflurane for maintaining anesthesia in breastfeeding women is deemed acceptable.
• The Academy of Breastfeeding Medicine recommends delaying elective surgery until the breastfeeding child is older and breastfeeding is well established.
• Before surgery, if possible, milk should be expressed.
• Typically, breastfeeding can resume or milk can be expressed once the mother is awake and in recovery, especially for healthy, full-term infants.
• For more vulnerable children, milk can be stored for later use when the risk is lower.

Desflurane (Suprane) Dose adjustment in renal disease:

No dosage adjustment is necessary.   

Desflurane (Suprane) Dose adjustment in liver disease:

No dosage adjustment is necessary.   

Common Side Effects of Desflurane (Suprane):

• Gastrointestinal:
  • Nausea
  • Vomiting
• Respiratory:
  • Cough
  • Breath-holding
  • Apnea

Rare Side Effects of Desflurane (Suprane):

• Cardiovascular:
  • Oxygen saturation decreased
  • Bradycardia
  • Hypertension (including malignant hypertension)
  • Nodal arrhythmia
  • Shivering
  • Tachycardia
• Central nervous system:
  • Headache
• Gastrointestinal:
  • Sialorrhea
• Ophthalmic:
  • Conjunctivitis
• Neuromuscular & skeletal:
  • Laryngospasm
• Respiratory:
  • Increased bronchial secretions
  • Pharyngitis

Contraindications to Desflurane (Suprane):

• Desflurane is not recommended for individuals with hypersensitivity to desflurane, other similar agents, or any components of its formulation.
• It should also be avoided in patients with a known or suspected genetic predisposition to malignant hyperthermia, as well as those for whom general anesthesia is not advised.
• Desflurane is contraindicated for pediatric patients during anesthesia induction.
• Additionally, individuals with a history of moderate to severe liver problems following anesthesia with desflurane or similar agents should avoid its use unless specifically recommended by a healthcare professional.
• In Canadian labeling, there are additional contraindications not listed in US labeling. These include a history of hepatitis due to a halogenated inhalational anesthetic or individuals who have experienced liver dysfunction, jaundice, unexplained fever, leukocytosis, or eosinophilia after previous administration of halogenated anesthetics. These individuals should also avoid desflurane.

Warnings and precautions

Reduced blood flow

• Desflurane can potentially lead to a decrease in blood flow to the liver and/or kidneys.
• This reduction in blood flow may affect the normal functioning of these organs, including their ability to filter toxins and metabolize substances.
• Therefore, caution is necessary when using desflurane, especially in patients with pre-existing liver or kidney conditions, as it may exacerbate their condition.
• Monitoring of liver and kidney function is typically performed during anesthesia to ensure patient safety.

Hepatitis

• Desflurane has the potential to trigger hepatitis, an inflammation of the liver, particularly in patients who have been sensitized by previous exposure to halogenated anesthetics.
• Sensitization refers to the development of an increased sensitivity or allergic reaction after prior exposure to a particular substance.
• Therefore, individuals with a history of hepatitis linked to previous use of halogenated anesthetics should exercise caution when considering desflurane for anesthesia.

Hyperkalemia:

• The use of inhaled anesthetics like desflurane has been linked to rare instances of perioperative hyperkalemia, a condition characterized by high levels of potassium in the blood, particularly in pediatric patients.
• Some reported cases involved the simultaneous use of succinylcholine, a muscle relaxant, but not all.
• Patients with underlying neuromuscular diseases, such as Duchenne muscular dystrophy, are at an increased risk of hyperkalemia.
• Additional abnormalities may include elevated levels of creatine kinase (CK) and myoglobinuria.
• It's crucial to closely monitor patients for any signs of arrhythmias and promptly identify and treat hyperkalemia if it occurs.

Increased intracranial pressure

• Desflurane can potentially dilate the blood vessels in the brain, which might lead to an increase in intracranial pressure under certain conditions.
• For patients with intracranial space-occupying lesions, it's recommended to administer desflurane at a maximum concentration of 0.8 MAC (minimum alveolar concentration) along with a barbiturate induction and hyperventilation before cranial decompression.
• It's crucial to maintain cerebral perfusion pressure to ensure adequate blood flow to the brain while managing intracranial pressure.
• This approach helps mitigate the risk of exacerbating intracranial pressure-related complications during anesthesia.

Malignant hyperthermia

• Desflurane use can potentially trigger malignant hyperthermia (MH), a rare but life-threatening condition characterized by a rapid rise in body temperature and muscle rigidity.
• In some reported cases, MH associated with desflurane has been fatal.
• Therefore, desflurane is contraindicated in patients who are susceptible to MH.
• It's essential for healthcare providers to be vigilant and promptly recognize any signs or symptoms of MH during anesthesia, such as rapid increase in body temperature, muscle rigidity, and metabolic acidosis, to initiate appropriate treatment and prevent adverse outcomes.

Extension of QT

• There have been reported cases of QT prolongation, a heart rhythm disorder, associated with inhaled anesthetic agents like desflurane.
• In some instances, this condition has led to torsade de pointes, a potentially fatal heart rhythm abnormality.
• It's important to exercise caution when administering desflurane to patients who are at risk of QT prolongation.
• This includes individuals taking medications known to prolong the QT interval, such as certain antiarrhythmic drugs (class Ia and III), elderly patients, and those with congenital QT prolongation.

Respiratory depression

• Desflurane can cause dose-dependent respiratory depression, meaning it can slow down breathing, especially when given in higher doses.
• It can also blunt the body's natural response to low oxygen levels and high carbon dioxide levels, which are important signals for regulating breathing.
• Desflurane may decrease the body's ability to constrict blood vessels in the lungs when oxygen levels are low, potentially leading to increased mixing of oxygen-poor blood with oxygen-rich blood.
• Additionally, in certain circumstances, desflurane exposure can lead to elevated levels of carbon monoxide and carboxyhemoglobin when there is a dry carbon dioxide absorbent in the anesthesia machine's breathing system.
• To prevent this, it's essential to maintain fresh absorbent according to the manufacturer's guidelines, regardless of the color of the indicator.
• This ensures the safe removal of carbon dioxide during anesthesia.

Cardiovascular disease

• Desflurane should not be used alone to induce anesthesia in patients with coronary artery disease (CAD) or those who should avoid increases in heart rate or blood pressure.
• When the inspired concentration of desflurane abruptly increases beyond a certain threshold (greater than 1 minimum alveolar concentration, MAC), there can be a transient rise in blood pressure and heart rate due to elevated levels of plasma catecholamines.
• This acute increase in desflurane concentration can lead to heightened sympathetic nervous system activity, which typically lasts for 2 to 4 minutes.
• However, this effect can be mitigated by using concurrent medications such as nitrous oxide, opioids, beta-blockers, and alpha-2 agonists.
• Desflurane's hypotensive effect, caused by peripheral vasodilation, becomes more pronounced as anesthesia deepens.
• Additionally, according to a scientific statement from the American Heart Association, desflurane has been identified as an agent that might worsen underlying myocardial dysfunction, indicating a significant concern.

Hepatic disease

• In patients with hepatic disease such as cirrhosis, viral hepatitis, or other liver conditions, caution should be exercised when considering the use of desflurane due to the risk of hepatitis associated with halogenated anesthetics.
• There have been reports of liver function disruption, jaundice, and even fatal liver necrosis, which may suggest hypersensitivity reactions.
• It's advisable to contemplate using an alternative anesthetic rather than a halogenated one in such cases to minimize the potential risks to the liver.

Desflurane: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy).
Alcohol (Ethyl)	CNS Depressants can increase the CNS depressant effects of Alcohol (Ethyl).
Alfuzosin	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Alizapride	CNS Depressants may increase the CNS depressant effects.
Antipsychotic Agents, Second Generation (Atypical)	Blood Pressure Lowering Agents can increase the hypotensive effects of Antipsychotic Agents (Second Gen [Atypical]).
Barbiturates	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Benperidol	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Blood Pressure Lowering Agents	May enhance the hypotensive effect of HypotensionAssociated Agents.
Brexanolone	CNS Depressants can increase the CNS depressant effects of Brexanolone.
Brimonidine (Topical)	CNS Depressants may increase the CNS depressant effects.
Brimonidine (Topical)	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Bromopride	CNS Depressants may increase the CNS depressant effects.
Cannabidiol	CNS Depressants may increase the CNS depressant effects.
Cannabis	CNS Depressants may increase the CNS depressant effects.
Chlorphenesin Carbamate	CNS Depressants may have an adverse/toxic effect that can be exacerbated by them.
CNS Depressants	Can increase the toxic/adverse effects of CNS Depressants.
Diazoxide	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Dimethindene (Topical).	CNS Depressants may increase the CNS depressant effects.
Doxylamine	CNS Depressants may have a greater CNS depressant effect if taken with other CNS Depressants. Management: The manufacturer of Diclegis (doxylamine/pyridoxine), intended for use in pregnancy, specifically states that use with other CNS depressants is not recommended.
Dronabinol	CNS Depressants may increase the CNS depressant effects.
DULoxetine	DULoxetine may increase hypotensive effects by lowering blood pressure.
EPINEPHrine (Nasal)	Inhalational anesthetics can increase the arrhythmogenic effects of EPINEPHrine.
EPINEPHrine (Oral Inhalation)	Inhalational Anesthesia may increase the arrhythmogenic effects of EPINEPHrine (Oral Inhalation).
Esketamine	CNS Depressants may increase the CNS depressant effects.
Fenoterol	Inhalational anesthetics can increase the arrhythmogenic effects of Fenoterol.
Formoterol	Formoterol's arrhythmogenic effects may be enhanced by inhalational anesthetics.
Haloperidol	QT-prolonging agents (Indeterminate risk - Caution), may increase the QTcprolonging effects of Haloperidol.
Herbs (Hypotensive properties)	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
HydrOXYzine	CNS Depressants may increase the CNS depressant effects.
Hypotension-Associated Agents	Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents.
Kava Kava	CNS Depressants may have an adverse/toxic effect that can be exacerbated by them.
Levodopa-Containing Products	Blood Pressure Lowering Agents can increase the hypotensive effects of Levodopa -Containing Products.
Lofexidine	CNS Depressants may have a greater depressant effect on the brain. Management: Separate drug interaction monographs are available for drugs listed as an exception to this monograph.
Lormetazepam	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Magnesium Sulfate	CNS Depressants may increase the CNS depressant effects.
MetyroSINE	MetyroSINE may have a sedative effect that can be enhanced by CNS depressants.
Minocycline	CNS Depressants may increase the CNS depressant effects.
Mirtazapine	CNS Depressants can increase the CNS depressant effects of Mirtazapine.
Molsidomine	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nabilone	CNS Depressants may increase the CNS depressant effects.
Naftopidil	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Neuromuscular-Blocking Agents (Nondepolarizing)	Inhalational Anesthetics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing).
Nicergoline	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nicorandil	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nitroprusside	The hypotensive effects of Nitroprusside may be enhanced by blood pressure lowering agents.
Pentoxifylline	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Pholcodine	Pholcodine may increase hypotensive effects by lowering blood pressure.
Phosphodiesterase 5 Inhibitors	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Piribedil	CNS Depressants could increase the CNS depressant effects of Piribedil.
Pramipexole	Pramipexole may have a greater sedative effect if it is combined with CNS depressants.
Prostacyclin Analogues	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Agents that prolong QT (Highest risk)	QT-prolonging agents (Indeterminate risk - Caution), may increase the QTc prolonging effect of QT Prolonging Agents. When using these agents together, be sure to monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Quinagolide	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Ritodrine	This may increase the toxic/adverse effects of Inhalational Anesthetics.
ROPINIRole	CNS Depressants can increase the sedative effects of ROPINIRole.
Rotigotine	CNS Depressants can increase the sedative effects of Rotigotine.
Rufinamide	CNS Depressants may have an adverse/toxic effect that can be exacerbated by this. Particularly, dizziness and sleepiness may be increased.
Selective Serotonin Reuptake inhibitors	CNS Depressants can increase the toxic/adverse effects of Selective Serotonin Resuptake Inhibitors. Particularly, psychomotor impairment could be increased.
Tetrahydrocannabinol	CNS Depressants may increase the CNS depressant effects.
Tetrahydrocannabinol, and Cannabidiol	CNS Depressants may increase the CNS depressant effects.
Trimeprazine	CNS Depressants may increase the CNS depressant effects.
Risk Factor D (Consider therapy modifications)
Amifostine	Amifostine's hypotensive effects may be enhanced by blood pressure lowering agents. Treatment: Blood pressure lowering drugs should be stopped 24 hours before amifostine administration. Amifostine should be avoided if blood pressure lowering medication cannot be withheld.
Bambuterol	May increase the arrhythmogenic effects of Inhalational Anesthesthetics. Management: Some labels advise against halothane use; others suggest that you separate the administration for at least 6 hours. Other bambuterol labels don't mention any possible interactions.
Blonanserin	CNS Depressants can increase the CNS depressant effects of Blonanserin.
Buprenorphine	CNS Depressants can increase the CNS depressant effects of buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Buprenorphine patches (Butrans) should be initiated at 5 mg/hr for adults. This is when it is combined with other CNS depression drugs.
Chlormethiazole	CNS Depressants may increase the CNS depressant effects. Monitoring: Look out for signs of CNS depression. If a combination of chlormethiazole and other drugs is required, a reduced dose should be used.
Droperidol	CNS Depressants may increase the CNS depressant effects. Management: Droperidol and other CNS agents, such as opioids, may be reduced or used in combination with droperidol. Separate drug interaction monographs provide more detail on exceptions to this monograph.
EPINEPHrine (Systemic)	Systemic may have an arrhythmogenic effect from inhalational anesthetics. Patients who are currently receiving or have received inhalational anesthetics should be administered epinephrine cautiously. Monitor for cardiac arrhythmias and use lower doses than usual.
Flunitrazepam	CNS Depressants can increase the CNS depressant effects of Flunitrazepam.
HYDROcodone	CNS Depressants can increase the CNS depressant effects of HYDROcodone. When possible, avoid concomitant use with hydrocodone, benzodiazepines, or other CNS depressionants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Methotrimeprazine	Methotrimeprazine may have a higher CNS depressant activity than CNS Depressants. Methotrimeprazine can increase the CNS depressant effects of CNS Depressants. Management: Lower the adult dose of CNS Depressants by 50% and start concomitant methotrimeprazine treatment. After clinically proven efficacy of methotrimeprazine, further CNS depressant dose adjustments should only be made.
Obinutuzumab	This may increase the hypotensive effects of Blood Pressure Lowering Agents. Management: You may temporarily withhold blood pressure lowering medication beginning 12 hours before obinutuzumab injection and continuing for 1 hour after infusion.
Opioid Agonists	CNS Depressants can increase the CNS depressant effects of Opioid Aggonists. Management: When possible, avoid concomitant use opioid agonists, benzodiazepines, or other CNS depressionants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
OxyCODONE	CNS Depressants can increase OxyCODONE's CNS depressant effects. When possible, avoid the simultaneous use of oxycodone and other CNS depressants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Perampanel	CNS Depressants may have a greater CNS depressant effect. Perampanel and any other CNS depressant drug should be used in combination. Patients who take perampanel together with other drugs that have CNS depressant activity should not engage in complex or high-risk activities until they are familiar with the combination.
Sodium Oxybate	CNS Depressants may have a greater depressant effect if taken in combination. Management: Look for alternatives to the combination use. If you must combine use, reduce the dose of any one or more drugs. It is not recommended to combine sodium oxybate and alcohol, or any sedative hypnotics.
Suvorexant	CNS Depressants can increase the CNS depressant effects of Suvorexant. Management: Suvorexant or any other CNS depressionant can be reduced in doses. Suvorexant should not be taken with alcohol. It is also not recommended to take suvorexant along with any other drugs for insomnia.
Tapentadol	CNS Depressants may increase the CNS depressant effects. Tapentadol, benzodiazepines and other CNS depressants should be avoided when possible. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Zolpidem	CNS Depressants can increase the CNS depressant effects of Zolpidem. Management: For men who also take CNS depressants, reduce the adult Intermezzo brand sublingual Zolpidem dose to 1.75mg. For women, no dose adjustment is advised. Avoid using CNS depressants at night; do not use alcohol.
Risk Factor X (Avoid Combination)
Azelastine (Nasal)	CNS Depressants could increase the CNS depressant effects of Azelastine.
Bromperidol	Bromperidol's hypotensive effects may be enhanced by Blood Pressure Lowering agents. Bromperidol could decrease the hypotensive effects of Blood Pressure Lowering agents.
Bromperidol	CNS Depressants may increase the CNS depressant effects.
Dexmethylphenidate	May increase the hypertensive effects of Inhalational Anesthestics.
DOPamine	Inhalational Anesthetics can increase the arrhythmogenic effects of DOPamine. Patients receiving halogenated Hydrocarbon Anesthetics should not use dopamine. Monitor for arrhythmia if concomitant treatment is not possible. Propranolol, based on animal data, may reverse ventricular arrhythmia caused by dopamine.
Ephedra	May increase the arrhythmogenic effects of Inhalational Anesthestics.
EPHEDrine (Nasal).	May increase the arrhythmogenic effects of Inhalational Anesthestics.
EPHEDrine (Systemic)	May increase the arrhythmogenic effects of Inhalational Anesthestics.
Isoproterenol	Inhalational anesthetics can increase the arrhythmogenic effects of Isoproterenol.
Metaraminol	Metaraminol's arrhythmogenic effects may be enhanced by inhalational anesthetics.
Methylphenidate	May increase the hypertensive effects of Inhalational Anesthestics.
Norepinephrine	Inhalational anesthetics can increase the arrhythmogenic effects of Norepinephrine.
Orphenadrine	Orphenadrine may be more effective against CNS depression than other drugs.
Oxomemazine	CNS Depressants may increase the CNS depressant effects.
Paraldehyde	Paraldehyde may be enhanced by CNS depressants.
Thalidomide	CNS Depressants can increase Thalidomide's CNS depressant effects.

Monitoring parameters:

• Blood Pressure, Heart Rate, and Rhythm:
  • Monitoring of blood pressure, heart rate, and heart rhythm is essential before and throughout anesthesia to ensure cardiovascular stability and detect any abnormalities promptly.
• Temperature:
  • Monitoring of body temperature helps in assessing the patient's physiological status and detecting any signs of hyperthermia or hypothermia during anesthesia.
• Oxygen Saturation:
  • Continuous monitoring of oxygen saturation ensures adequate oxygen delivery to tissues and early detection of hypoxemia, a condition where there is an insufficient amount of oxygen in the blood.
• End-Tidal CO₂ and Desflurane Concentrations:
  • Monitoring end-tidal CO₂ levels provides information about the patient's ventilation status, while monitoring end-tidal desflurane concentrations helps in controlling the depth of anesthesia and preventing overdose.

Special Considerations for Pediatric Patients

• Adverse Respiratory Symptoms (≤6 years):
  • Pediatric patients, especially those aged 6 years and below, should be closely monitored for any adverse respiratory symptoms during anesthesia, as they may have a limited ability to express discomfort or distress.
• Signs and Symptoms of Airway Narrowing:
  • Children with asthma or recent upper respiratory infections should be carefully observed for signs and symptoms of airway narrowing during anesthesia, as they are at increased risk of experiencing respiratory complications. Early detection allows for prompt intervention to prevent complications.

How to administer Desflurane (Suprane)?

Via Desflurane-Specific Calibrated Heated Vaporizer:

• Desflurane is administered through a specialized vaporizer designed specifically for its use.
• The vaporizer is calibrated to ensure accurate delivery of desflurane concentrations.
• Heating is applied to maintain desflurane in its gaseous state for precise administration during anesthesia.

Mechanism of action of Desflurane (Suprane):

• Desflurane is believed to induce general anesthesia by increasing the activity of inhibitory postsynaptic channels while simultaneously decreasing excitatory synaptic activity, although the exact mechanisms are not fully understood.
• This combination of effects results in the suppression of neural activity, leading to the loss of consciousness and pain sensation during surgery.

Onset of Action

• 1 to 2 minutes:
  • Desflurane typically begins to take effect within 1 to 2 minutes after administration, inducing anesthesia relatively quickly compared to other agents.

Duration

• Emergence Time:
  • The time it takes for a patient to wake up from anesthesia with desflurane depends on the concentration of the drug in their bloodstream at the time it is discontinued.

Metabolism

• Hepatic Metabolism:
  • Desflurane is primarily metabolized in the liver, with only a small fraction (approximately 0.02%) undergoing metabolic transformation to trifluoroacetate and inorganic fluoride.

Excretion

• Exhaled Gases:
  • Desflurane is eliminated from the body primarily through exhalation as part of the exhaled gases during respiration.

International Brands of Desflurane:

• Suprane
• Sulorane

Desflurane Brands in Pakistan:

Not available.