An inhalational anaesthetic called sevoflurane is used to induce and maintain general anaesthesia.
Sevoflurane Uses:
-
Anesthesia:
- Used for both inpatient and outpatient surgery in adults and children to initiate and maintain general anaesthesia
Sevoflurane Dose in Adults
Sevoflurane Dose in Anesthesia:
-
Inhalation:
- With or without the use of nitrous oxide, concentrations between 0.5% and 3% are often needed to reach surgical levels of anaesthesia; 0.6% is the level at which amnesia and loss of awareness start to happen.
-
MAC values for surgical levels of anesthesia:
-
25 years:
- Sevoflurane in oxygen: 2.6%
- Sevoflurane in 65% N 0/35% oxygen: 1.4%
-
40 years:
- Sevoflurane in oxygen: 2.1%
- Sevoflurane in 65% N 0/35% oxygen: 1.1%
-
60 years:
- Sevoflurane in oxygen: 1.7%
- Sevoflurane in 65% N 0/35% oxygen: 0.9%
-
80 years:
- Sevoflurane in oxygen: 1.4%
- Sevoflurane in 65% N 0/35% oxygen: 0.7%
-
Sevoflurane Dose in Children
Sevoflurane Dose in Anesthesia:
-
Inhalation:
- With or without the use of nitrous oxide, concentrations between 0.5% and 3% are often needed to reach surgical levels of anaesthesia; 0.6% is the level at which amnesia and loss of awareness start to happen.
-
MAC values for surgical levels of anesthesia:
-
0 to 1-month-old full-term neonates:
- Sevoflurane in oxygen: 3.3%
-
1 to <6 months:
- Sevoflurane in oxygen: 3%
-
6 months to <1 year:
- Sevoflurane in oxygen: 2.8%
- Sevoflurane in 65% N 0/35% oxygen: 2%
-
1 to <3 years:
- Sevoflurane in oxygen: 2.8%
- Sevoflurane in 60% N 0/40% oxygen: 2%
-
3 to 12 years:
- Sevoflurane in oxygen: 2.5%
-
Pregnancy Risk Category: B
- It can also cross the placenta.
- Results from animal studies demonstrate that prolonged or recurrent use of general anaesthetics and sedative drugs that block N-methyl D-aspartate receptors (NMDA) and/or inhibit gamma-aminobutyric acid can have an impact on brain development (GABA). The third trimester is the most dangerous for human foetuses.
- It's critical to weigh the advantages and disadvantages of sevoflurane medication for expectant mothers, especially for procedures lasting more than three hours.
- It has been reported that Sevoflurane can be used in obstetrical anesthesia.
- Avoiding maternal exposure is important as it can cause uterine relaxation and fetal depress. There have been no adverse reactions to general anesthesia used for elective c section delivery.
- Regardless of the trimester, ACOG advises pregnant women to not object to medically necessary surgeries or procedures.
- Non-urgent surgery should not be performed during the second trimester. Avoid elective surgery until after delivery.
Use while breastfeeding
- Sevoflurane may or may not be found in breast milk.
- However, it is quickly washed out so its levels are unlikely to be of any clinical significance 1 day after anesthesia.
- The Academy of Breast Feeding Medicine recommends postponing elective surgery until your child is more mature and established in breastfeeding.
- When possible, express milk should be used before surgery.
- A healthy, full-term baby can resume breastfeeding or express milk once she is awake and well.
- Save milk for vulnerable children to use later when they are at lower risk.
Dose in Kidney Disease:
No dosage adjustments have been provided in the manufacturer's labeling; use cautiously in patients with creatinine >1.5 mg/dL (safety not established).
Dose in Liver disease:
No dosage adjustments have been provided in the manufacturer's labeling; use cautiously. The safety in patients with severe hepatic impairment has not been studied
Common Side Effects of Sevoflurane:
-
Cardiovascular:
- Hypotension
-
Central Nervous System:
- Agitation
-
Gastrointestinal:
- Nausea
- Vomiting
-
Respiratory:
- Cough
Less Common Side Effects of Sevoflurane:
-
Cardiovascular:
- Tachycardia
- Bradycardia
- Hypertension
-
Central Nervous System:
- Drowsiness
- Shivering
- Dizziness
- Headache
- Hypothermia
- Myoclonus
- Delirium
-
Gastrointestinal:
- Sialorrhea
-
Respiratory:
- Airway Obstruction
- Laryngospasm
- Breath-Holding
- Apnea
-
Miscellaneous:
- Fever
Contraindications to Sevoflurane:
- Hypersensitivity to sevoflurane or other halogenated painkillers, or any component in the formulation
- Malignant hyperthermia susceptibility (known or suspected).
Canadian labeling: Additional contraindications not in US labeling
- Previous administrations of halogenated anesthetics have caused liver dysfunction, jaundice or unexplained febrile illness, such as leukocytosis or eosinophilia.
- Contraindications to general anesthesia
Warnings and precautions
-
Agitation/delirium
- You should monitor for any emergence agitation, delirium or other symptoms.
-
Hepatic effects
- Rarely, hepatitis post-operatively or hepatic dysfunction may occur with or without jaundice. The risk of developing a halogenated hydrocarbon anesthetic reaction is higher if you have had previous exposure.
-
Hyperkalemia
- Pediatric patients have experienced perioperative hyperkalemia on occasion. Some cases, although not all, have involved the use of inhaled anaesthetics.
- Latent and overt neuromuscular diseases (eg Duchenne muscular dystrophy) were the most vulnerable. Other abnormalities include elevated CPK or myoglobinuria. Monitor closely for arrhythmias. Recognize and treat hyperkalemia and resistive arrhythmias immediately.
-
Hypotension
- A dose-dependent decrease in blood pressure can occur during maintenance anesthesia. This may be more rapid than other inhaled anesthetics.
-
Increased intracranial pressure
- Vasodilation of the cerebral vasculature may occur, and in some cases, it may raise intracranial pressure.
-
Malignant hyperthermia
- The onset of malignant hyperthermia is possible. There have been some reported fatal cases. It is not advised for patients to use this medication if they have specific hereditary mutations in the ryanodine receptor.
-
Extension of QT
- Several studies have linked sevoflurane to QT prolongation (some fatal). In patients who have a high risk of QT prolongation, exercise cautious.
-
Respiratory depression
- It is possible to develop dose-dependent respiratory depression, blunted ventilatory responses to hypoxia or hypercapnia, and dose-dependent respiratory depression. This can cause a decrease in hypoxic pulmonary vasoconstriction, which can lead to an increase in pulmonary shunt.
-
Heart Failure:
- The American Heart Association has stated that sevoflurane may be an agent that can exacerbate myocardial dysfunction.
-
Hepatic impairment
- Patients with severe hepatic impairment should be cautious. It is not known if the drug is safe in patients with severe liver impairment.
-
Renal impairment
- Patients with kidney impairment (ie creatinine >1.5 mg/dL) should be cautious.
- It has not been proven safe for patients with severe renal impairment.
-
Seizure disorder
- Patients at high risk of seizures should be treated with caution Children and young adults may experience seizures.
Sevoflurane: Drug Interaction
|
Alcohol (Ethyl) |
Alcohol's CNS depressing effect may be amplified by CNS depressants (Ethyl). |
|
Alfuzosin |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Alizapride |
CNS depressants may have an enhanced CNS depressant impact. |
|
Antipsychotic Agents (Second Generation [Atypical]) |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). |
|
Barbiturates |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Benperidol |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Blood Pressure Lowering Agents |
May enhance the hypotensive effect of Hypotension-Associated Agents. |
|
Brexanolone |
Brexanolone's CNS depressing effects may be amplified by other CNS depressants. |
|
Brimonidine (Topical) |
May enhance the CNS depressant effect of CNS Depressants. |
|
Brimonidine (Topical) |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Bromopride |
May enhance the CNS depressant effect of CNS Depressants. |
|
Cannabidiol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Cannabis |
May enhance the CNS depressant effect of CNS Depressants. |
|
Chlorphenesin Carbamate |
May enhance the adverse/toxic effect of CNS Depressants. |
|
CNS Depressants |
May enhance the adverse/toxic effect of other CNS Depressants. |
|
Diazoxide |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Dimethindene (Topical) |
May enhance the CNS depressant effect of CNS Depressants. |
|
Doxylamine |
May enhance the CNS depressant effect of 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 |
May enhance the CNS depressant effect of CNS Depressants. |
|
DULoxetine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. |
|
EPINEPHrine (Nasal) |
The arrhythmogenic effects of inhaled anaesthetics may be increased (Nasal). |
|
EPINEPHrine (Oral Inhalation) |
The arrhythmogenic effects of inhaled anaesthetics may be increased (Oral Inhalation). |
|
Esketamine |
CNS depressants may have an enhanced CNS depressant impact. |
|
Fenoterol |
Fenoterol's ability to induce arrhythmias may be enhanced by inhalational anaesthetics. |
|
Formoterol |
The arrhythmogenic impact of formoterol may be enhanced by inhalational anaesthetics. |
|
Haloperidol |
QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTcprolonging effect of Haloperidol. |
|
Herbs (Hypotensive Properties) |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
HydrOXYzine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Hypotension-Associated Agents |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. |
|
Isoniazid |
May decrease the serum concentration of CYP2E1 Substrates (High risk with Inhibitors). Specifically, it may decrease CYP2E1 substrate serum concentrations below baseline after isoniazid discontinuation. Isoniazid may increase the serum concentration of CYP2E1 Substrates (High risk with Inhibitors). |
|
Kava Kava |
CNS depressants' harmful or toxic effects could be increased. |
|
Levodopa-Containing Products |
Levodopa-Containing Products' hypotensive effects may be strengthened by blood pressure-lowering medications. |
|
Lofexidine |
CNS depressants may have an enhanced CNS depressant impact. Management: Separate drug interaction monographs go into further detail about the medications indicated as exceptions to this book. |
|
Lormetazepam |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Magnesium Sulfate |
CNS depressants may have an enhanced CNS depressant impact. |
|
MetyroSINE |
The sedative effects of metyroSINE may be strengthened by CNS depressants. |
|
Minocycline |
CNS depressants may have an enhanced CNS depressant impact. |
|
Mirtazapine |
CNS Depressants may enhance the CNS depressant effect of Mirtazapine. |
|
Molsidomine |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nabilone |
May enhance the CNS depressant effect of CNS Depressants. |
|
Naftopidil |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Neuromuscular-Blocking Agents (Nondepolarizing) |
The neuromuscular-blocking impact of neuromuscular-blocking agents may be enhanced by inhaled anaesthetics (Nondepolarizing) |
|
Nicergoline |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Nicorandil |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Nitroprusside |
Nitroprusside's hypotensive impact may be strengthened by blood pressure-lowering medications. |
|
Pentoxifylline |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Pholcodine |
Pholcodine's hypotensive impact may be strengthened by blood pressure lowering medications. |
|
Phosphodiesterase 5 Inhibitors |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Piribedil |
Piribedil's CNS depressing effects may be enhanced by other CNS depressants. |
|
Pramipexole |
The sedative effects of pramipexole might be enhanced by CNS depressants. |
|
Prostacyclin Analogues |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
QT-prolonging Agents (Highest Risk) |
The QTc-prolonging action of QT-prolonging Agents may be enhanced by QT-prolonging Agents (Indeterminate Risk - Caution) (Highest Risk). When using these medications together, watch out for cardiac arrhythmias and a prolonged QTc interval. Individuals may be considerably more at risk for QTc prolongation if they have additional risk factors. |
|
Quinagolide |
The hypotensive effects of blood pressure-lowering medications may be strengthened. |
|
Ritodrine |
May enhance the adverse/toxic effect of Inhalational Anesthetics. |
|
ROPINIRole |
CNS Depressants may enhance the sedative effect of ROPINIRole. |
|
Rotigotine |
CNS Depressants may enhance the sedative effect of Rotigotine. |
|
Rufinamide |
May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. |
|
Selective Serotonin Reuptake Inhibitors |
CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. |
|
Tetrahydrocannabinol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Tetrahydrocannabinol and Cannabidiol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Trimeprazine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Risk Factor D (Consider therapy modification) |
|
|
Amifostine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. |
|
Bambuterol |
|
|
Blonanserin |
CNS Depressants may enhance the CNS depressant effect of Blonanserin. |
|
Buprenorphine |
CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. |
|
Chlormethiazole |
May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. |
|
CYP2E1 Inhibitors (Strong) |
May decrease the metabolism of CYP2E1 Substrates (High risk with Inhibitors). |
|
Droperidol |
CNS depressants may have an enhanced CNS depressant impact. Consider lowering the dosage of droperidol or other CNS drugs (such as opioids or barbiturates) when they are used concurrently. In separate drug interaction monographs, exceptions to this monograph are covered in more detail. |
|
EPINEPHrine (Systemic) |
The arrhythmogenic effects of inhaled anaesthetics may be increased (Systemic). Treatment: When treating patients who are now receiving or have just had inhalational anaesthetics, provide epinephrine with extra caution. Employ epinephrine at lower dosages than usual and keep an eye out for the emergence of cardiac arrhythmias. |
|
Flunitrazepam |
CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. |
|
HYDROcodone |
CNS Depressants may enhance the CNS depressant effect of HYDROcodone. Management: Avoid concomitant use of hydrocodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Methotrimeprazine |
CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established. |
|
Obinutuzumab |
The hypotensive effects of blood pressure-lowering medications may be strengthened. Management: Take into account temporarily stopping blood pressure-lowering drugs 12 hours before the start of the obinutuzumab infusion and keeping them off until 1 hour after the infusion is finished. |
|
Opioid Agonists |
CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
OxyCODONE |
CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Perampanel |
May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. |
|
Sodium Oxybate |
May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to combined use. When combined use is needed, consider minimizing doses of one or more drugs. Use of sodium oxybate with alcohol or sedative hypnotics is contraindicated. |
|
Suvorexant |
CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. |
|
Tapentadol |
May enhance the CNS depressant effect of CNS Depressants. Management: Avoid concomitant use of tapentadol and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Zolpidem |
CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. |
|
Risk Factor X (Avoid combination) |
|
|
Azelastine (Nasal) |
CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal). |
|
Bromperidol |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. |
|
Bromperidol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Dexmethylphenidate |
May enhance the hypertensive effect of Inhalational Anesthetics. |
|
DOPamine |
DOPamine's ability to induce arrhythmias may be enhanced by inhalational anaesthetics. Management: Patients receiving halogenated hydrocarbon anaesthetics should not be given dopamine. Watch for arrhythmia if concurrent treatment cannot be avoided. Based on studies from animals, propranolol may be able to reverse ventricular arrhythmia caused by dopamine. |
|
Ephedra |
Can make inhalational anaesthetics more arrhythmogenic. |
|
EPHEDrine (Nasal) |
Can make inhalational anaesthetics more arrhythmogenic. |
|
EPHEDrine (Systemic) |
Can make inhalational anaesthetics more arrhythmogenic. |
|
Isoproterenol |
Can make inhalational anaesthetics more arrhythmogenic. |
|
Metaraminol |
Anesthetics for inhalation may increase the arrhythmogenic potential of metaraminol. |
|
Methylphenidate |
Inhalational anaesthetics' tendency to cause hypertension may be enhanced. |
|
Norepinephrine |
Norepinephrine's ability to induce arrhythmias may be enhanced by inhalational anaesthetics. |
|
Orphenadrine |
Orphenadrine's CNS depressant effects may be amplified by CNS depressants. |
|
Oxomemazine |
CNS depressants may have an enhanced CNS depressant impact. |
|
Paraldehyde |
The CNS depressing effects of paraldehyde may be enhanced by CNS depressants. |
|
Thalidomide |
The CNS depressing effect of thalidomide may be enhanced by CNS depressants. |
Monitoring parameters:
- Blood pressure
- Temperature,
- Heart rate and rhythm
- O2 saturation
- Monitor end-tidal CO2 and end-tidal sevoflurane concentrations prior to and throughout anesthesia
- The temperature of CO2 absorbent canister
How to administer Sevoflurane?
Use caution when administering sevoflurane in low-flow or closed-circuit systems since it is unstable and may release potentially harmful breakdown products. Sevoflurane-specific calibrated vaporizers are utilised for this purpose.
Mechanism of action of Sevoflurane:
- Inhaled anesthetics can cause alteration of the activity neuronal ion channel activity, particularly fast synaptic neurotransmitter receivers (nicotinic Acetylcholine and GABA receptors).
- The effects of sevoflurane on sympathetic stimulation, including the cardiovascular system, are very limited.
- Sevoflurane does not cause respiratory irritation or circulatory stimulation. The drug may cause myocardial contractility to decrease, and systemic vascular resistance to decrease.
- Blood pressure and sympathetic nerve activity may drop as a result.
- Sevoflurane has an immediate start and quick recovery because of its low blood/gas partition coefficient.
The onset of action: Induction time is within 2 to 3 minutes
Duration:
- Time to emerge: Determined by blood concentration at the time sevoflurane is stopped. Because to sevoflurane's limited blood gas solubility, the anaesthetic concentration in the lung changes quickly (0.63).
- While anaesthesia lasts less than two hours, sevoflurane's 90% decrement time (the amount of time needed for an anaesthetic concentration in vessel-rich tissues to fall by 90%) is brie
Metabolism: In liver (~5%) via CYP2E1
Excretion: Exhaled gases
International Brand Names of Sevoflurane:
- Sojourn
- Amasevo
- Floves
- Haluran
- Sefether
- Sevo
- Sevocris
- Sevodex
- Sevofran
- Sevofrane
- Sevoran
- Sevorane
- Sevotan
- Sojourn
- Sovener
- Ultane
Sevoflurane Brand Names in Pakistan:
Brands will be updated later.
