Hindawi Publishing Corporation

BioMed Research International

Volume 2016, Article ID 3068467, 5 pages
http://dx.doi.org/10.1155/2016/3068467

Clinical Study
Effects of Low-Flow Sevoflurane Anesthesia on
Pulmonary Functions in Patients Undergoing Laparoscopic
Abdominal Surgery

Cihan Doger,1 Kadriye Kahveci,2 Dilsen Ornek,3 Abdulkadir But,4

Mustafa Aksoy,4 Derya Gokcinar,2 and Didem Katar5
1
Department of Anesthesiology and Reanimation, Ankara Ataturk Training and Research Hospital, 06800 Ankara, Turkey
2
Department of Anesthesiology and Reanimation, Ulus State Hospital, 06050 Ankara, Turkey
3
Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, 06230 Ankara, Turkey
4
Department of Anesthesiology and Reanimation, Faculty of Medicine, Yildirim Beyazit University, 06800 Ankara, Turkey
5
Department of Pulmonology, Ankara Yenimahalle State Hospital, 06370 Ankara, Turkey

Correspondence should be addressed to Cihan Doger; cihandoger@gmail.com

Received 18 February 2016; Revised 18 April 2016; Accepted 31 May 2016

Academic Editor: Joshua Lawson

Copyright © 2016 Cihan Doger et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. The aim of this prospective, randomized study was to investigate the effects of low-flow sevoflurane anesthesia on the
pulmonary functions in patients undergoing laparoscopic cholecystectomy. Methods. Sixty American Society of Anesthesiologists
(ASA) physical status classes I and II patients scheduled for elective laparoscopic cholecystectomy were included in the study.
Patients were randomly allocated to two study groups: high-flow sevoflurane anesthesia group (Group H, 𝑛 = 30) and low-flow
sevoflurane anesthesia group (Group L, 𝑛 = 30). The fresh gas flow rate was of 4 L/min in high-flow sevoflurane anesthesia group
and 1 L/min in low-flow sevoflurane anesthesia group. Heart rate (HR), mean arterial blood pressure (MABP), peripheral oxygen
saturation (SpO2 ), and end-tidal carbon dioxide concentration (ETCO2 ) were recorded. Pulmonary function tests were performed
before and 2, 8, and 24 hours after surgery. Results. There was no significant difference between the two groups in terms of HR,
MABP, SpO2 , and ETCO2 . Pulmonary function test results were similar in both groups at all measurement times. Conclusions. The
effects of low-flow sevoflurane anesthesia on pulmonary functions are comparable to high-flow sevoflurane anesthesia in patients
undergoing laparoscopic cholecystectomy.

1. Introduction the accumulation of potentially toxic gases. Low-flow anes-

thesia is the issue before the Y piece as connection point with
The use of the low-flow anesthesia technique provides pro- tube/circle system. That means that if low-flow anesthesia
tection of the heat and humidity of the respiratory system, is used successfully in a patient, it will never have different
while minimizing cost and preventing air pollution. The effects on pulmonary functions in comparison with higher
physiology of the tracheobronchial environment is protected flow anesthesia. It only affects the waste gas amount normally.
as mucociliary clearance is more excellently maintained in a Laparoscopic techniques compared with open surgery
low-flow anesthesia technique than in high-flow anesthesia are more widely preferred in the surgical field, because they
[1–4]. Moreover, as the waste gases are reduced, atmospheric require a shorter hospital stay and cause less morbidity and
pollution is lowered, health risks for operating room staff are mortality [5]. In laparoscopic surgery, the field of interest may
decreased, and ecological balances are maintained. However, be visualized by forming an artificial pneumoperitoneum.
possible disadvantages resulting from the inappropriate use The pneumoperitoneum is created by insufflating CO2 into
of low-flow anesthesia include hypoxia, excessive or insuf- the peritoneal cavity at a mean flow rate of 1-2 L/min.
ficient concentrations of volatile agents, hypercapnia, and The pneumoperitoneum has both mechanical and chemical
2 BioMed Research International

effects on the pulmonary system. With the first insuffla- and the fresh gas flow was changed to 6 L/min of oxygen.
tion, intra-abdominal pressure is increased, causing the Neuromuscular blockade was reversed by administering
diaphragm to be distended upward. This distension increases neostigmine (0.04 mg/kg IV) and atropine (0.02 mg/kg IV).
intrathoracic pressure, and the alveoli are collapsed. During The patient was extubated when the patient met the criteria
the laparoscopy, the direct effects of the additional positive for tracheal extubation (respiratory rate >8, spontaneous
end-expiratory pressure cause a hemodynamic imbalance [5– breathing with a minimum of 8 mL/kg body weight, ability
7]. to sustain a 5 s head lift, sustained hand grip, and sustained
Few studies have explored the low-flow sevoflurane arm lift). Fresh barium hydroxide was used to fill the carbon
anesthesia technique for laparoscopic abdominal surgery. In dioxide-absorbent canister before each patient.
this study, we aimed to investigate the effects of low-flow
sevoflurane anesthesia on pulmonary functions in patients 2.2. Measurements. Pulmonary function tests were per-
who underwent laparoscopic cholecystectomy. formed before and after the surgery at 2nd, 8th, and 24th
hours. Forced vital capacity (FVC, L), forced expiratory
volume in 1 s (FEV1, L), and forced expiratory volume in
2. Methods 1 s/forced vital capacity (FEV1/FVC %) values were measured
Approval for this study was obtained from the Ethics Com- using the spirometer (KoKo Legend 314000 Spirometer,
mittee at the University of Yildirim Beyazit, Faculty of nSpire Health, USA) by the same physician and the patients
Medicine, with number 2012-T4137-03-333. It conforms to the performed the forced expiratory maneuver at least three
provisions of the Declaration of Helsinki. Written informed times in the sitting position. The pulmonary function test
consent was obtained from all patients. Seventy patients results were expressed as percentages of the expected values
(20–55 years old) scheduled to have elective laparoscopic adjusted for age, height, body weight, and sex [8]. HR, MABP,
cholecystectomy and classified as American Society of Anes- and SpO2 were monitored and recorded after tracheal intu-
thesiologists physical status class I or II were prospectively bation and at 5 min intervals during intraoperative period.
enrolled. Patients with obstructive pulmonary disease and ETCO2 values were noted 5 min (T1), 10 min (T2), 20 min
cardiac or renal or hepatic disease, smokers, and those fasting (T3), 30 min (T4), 40 min (T5), 50 min (T6), and 60 min (T7)
for more than 12 hours were excluded. A web application after tracheal intubation. The anesthetist who evaluated and
(https://www.randomizer.org/) was used for randomization. recorded the data was blind to the group allocation.
Patients were randomly allocated to two study groups: high-
flow sevoflurane anesthesia group (Group H) and low-flow 2.3. Statistical Analysis. The power value was evaluated with
sevoflurane anesthesia group (Group L). The patients were the G-power 3.1 package program. An a priori power analysis
blind to which group they were in, but the intraopera- was based on previously published study [8]. The sample sizes
tive anesthesia team were informed about anesthesia and were calculated on the assumption that a 20% difference in
method. But both postoperative pulmonology and anesthesi- FEV1 and FVC was significant. In accordance with the power
ology doctor, who evaluated pulmonary function tests, were calculation method, to demonstrate a 20% difference at 𝛼 =
blinded. 0.05 and a power of 85%, 30 patients per group were required.
Statistical evaluation of the data was performed using SPSS
ver. 16.0 (SPSS, Chicago, IL, USA). Kolmogorov-Smirnov test
2.1. Anesthesia. All patients were premedicated with mida- was used to identify the distribution of variables. Results are
zolam at a dose of 0.02 mg/kg intravenously (IV) 30 min- expressed as mean ± SD or ratio of patients. Comparison
utes before the operation. Heart rate (HR), noninvasive between the two groups was performed using Mann-Whitney
mean arterial blood pressure (MABP), peripheral oxygen 𝑈, Wilcoxon Sign Test, or paired 𝑡-test. The results were
saturation (SpO2 ), and end-tidal carbon dioxide concentra- evaluated at a 95% confidence interval at a significance level
tion (ETCO2 ) were monitored. All patients were induced of 𝑃 < 0.05.
by fentanyl (1 𝜇g/kg IV) and propofol (3–5 mg/kg IV)
and muscle relaxation was achieved by administration of
atracurium (0.5 mg/kg IV). Anesthesia was maintained at 3. Results
3.4% sevoflurane and 50% nitrous oxide in oxygen. Patients
Three patients with lung disease, one patient with cardiac
in Group H received fresh gas flow of 4 L/min throughout
the procedure. Patients in Group L received a fresh gas disease, three smokers, and one patient switching from
laparoscopic cholecystectomy to open cholecystectomy were
flow rate of 4 L min−1 for the first 10 min and then were
excluded. Also two of the patients, who had operations lasting
maintained with a fresh gas flow of 1 L/min. All patients were
mechanically ventilated with a tidal volume of 8 mL/kg and longer than one hour because of surgical problems that
a frequency of 12 breaths/min with the ventilatory (Dräger may result in altering the postoperative pulmonary function
Julian, Lübeck, Germany) rate adjusted to maintain ETCO2 tests, were excluded. Sixty patients completed the study. The
of 30 to 40 mmHg. Atracurium (10 mg IV) was administered demographic data are shown in Table 1. The groups were
every 20 minutes. Hemodynamic functions were maintained similar in demographic characteristics.
within 20% of baseline by adjusting supplemental fentanyl No significant differences were found between the two
injection, as well as vasoactive drugs as needed. Sevoflurane groups in terms of HR, MABP, SpO2 , and ETCO2 during
was discontinued with the beginning of the skin sutures anesthesia. Although mean ETCO2 levels in Group L were
BioMed Research International 3

Table 1: Demographic characteristics and findings. 4. Discussion

Group H (𝑛 = 30) Group L (𝑛 = 30) 𝑃 value The present study shows that the effects of low-flow sevoflu-
Age (years) 44.77 ± 9.21 44.57 ± 9.87 0.936 rane anesthesia on pulmonary functions in patients under-
Sex (male/female) 3/27 3/27 1.000 going laparoscopic cholecystectomy were comparable to the
Weight (kg) 76.4 ± 9.42 75.9 ± 11.98 0.858 effects of high-flow sevoflurane anesthesia. Laparoscopic
Height (cm) 164.13 ± 7.08 163.10 ± 5.50 0.530 cholecystectomy is often used as an alternative to laparo-
Body mass index 28.56 ± 4.5 28.67 ± 5.12 0.927 tomy due to its advantages, including shorter hospital stays,
earlier mobilization, smaller incisions, a low incidence of
ASA class (I/II) 20/10 19/11 0.788
postoperative pain, and less need for analgesics [5, 6]. During
Operative time (min) 47.93 ± 4.91 46.28 ± 18.5 0.787
laparoscopic cholecystectomy, as a result of CO2 insufflation,
Values are expressed as ratio or mean ± SD. intra-abdominal pressure is increased, the movement of the
Group H: high-flow sevoflurane anesthesia group.
Group L: low-flow sevoflurane anesthesia group.
diaphragm is restricted, and the functional residual capacity
(FRC) is decreased. Hypercarbia can also occur due to
decreased FRC and CO2 absorption [6, 7]. Baraka et al. [7]
Table 2: Comparison of the preoperative and postoperative forced reported that, during the laparoscopic interventions, end-
expiratory volume in 1 s forced vital capacity and forced expiratory tidal CO2 showed a progressive increase following induction
volume in 1 s/forced vital capacity values. when the ventilation parameters were constant. Low-flow
Group H Group L 𝑃 value
anesthesia has some disadvantages, such as hypoxia, overdose
of anesthetic agent, and hypercapnia [9]. At the onset of low-
FEV1 (L)
flow anesthesia, the clearance of nitrogen from the blood
Preoperative 2.85 ± 0.69 2.78 ± 0.54 0.643 by giving high-flow 100% O2 ventilation for 10–20 minutes
Postoperative 2 h 2.37 ± 0.73 2.22 ± 0.54 0.723 ensures an easier distribution of the anesthetic gases into the
Postoperative 8 h 2.44 ± 0.68 2.46 ± 0.54 0.865 system and a more convenient adjustment of the gas con-
Postoperative 24 h 2.69 ± 0.78 2.72 ± 0.56 0.868 centrations. It has been demonstrated that the replacement
FVC (L) of nitrogen with oxygen in the lungs increased the oxygen
Preoperative 3.13 ± 0.74 3.10 ± 0.57 0.904 reserve and thereby the apnea time [10]. In our patients,
Postoperative 2 h 2.51 ± 0.84 2.47 ± 0.48 0.756 although ETCO2 levels during the low-flow anesthesia period
Postoperative 8 h 2.73 ± 0.77 2.69 ± 0.52 0.805 were found to be higher in Group L than in Group H,
the difference was not statistically significant, and increased
Postoperative 24 h 2.95 ± 0.79 2.96 ± 0.55 0.952
CO2 levels did not result in clinical complications. With a
FEV1/FVC (%)
decreasing flow rate, the difference between the concentra-
Preoperative 0.92 ± 0.10 0.90 ± 0.07 0.272 tion of O2 in the fresh gas mixture and the concentration of
Postoperative 2 h 0.93 ± 0.06 0.90 ± 0.08 0.074 O2 in the inspired air is increased. If low FiO2 is inspired
Postoperative 8 h 0.91 ± 0.09 0.92 ± 0.05 0.473 during rebreathing, a potential risk of hypoxia occurs. To
Postoperative 24 h 0.91 ± 0.10 0.91 ± 0.07 0.988 definitively prevent hypoxemia and to ensure a continuous
Values are expressed as mean ± SD. and adequate O2 presentation, the concentration of O2 in
FEV1: forced expiratory volume in 1 s. the inspirium should be at least 30% [10]. Okada et al. [11]
FVC: forced vital capacity. in their low-flow anesthesia sevoflurane study found that
FEV1/FVC: forced expiratory volume in 1 s/forced vital capacity.
the difference between FiO2 and O2 increased with time as
the inspired oxygen concentration (FiO2 ) values increased.
However, reductions in FiO2 to less than 30% were not seen
higher than those in Group H, the difference was not in any patients in the two groups.
statistically significant. Higher CO2 levels did not result in In our study, we used a mixture of 50% O2 and 50% N2 O.
clinical complication in any patient. The concentration of O2 in the inspired air was monitored.
Preoperative and postoperative pulmonary function test In none of the subjects did FiO2 fall below 42% during
results were similar in both groups. In all patients, the FVC the operation. Although decreases in the concentration of
and FEV1 values were significantly decreased in all measure- inspired and expired O2 were observed, it never fell to a
ments in the postoperative period compared to preoperative clinically significant level.
values, and this decrease was most pronounced during the As inspired and expired gases are mixed during the
second hour of the postoperative period. We also compared administration of low-flow anesthesia, the concentration of
the postoperative FEV1/FVC ratio to the preoperative values inspired gas is not directly correlated with the settings of
and found no statistically significant differences between the the vaporizer. One of the important dangers of the low-
two groups (Table 2). flow anesthesia technique is the elevation of circulating the
There was not any contamination whereby the protocols anesthetic concentration to levels so much higher than the
were altered for any patients in either the low-flow or the concentrations set in the vaporizer [12, 13]. However, during
high-flow groups with regard to the intervention specifically the administration of low-flow anesthesia, it is not very likely
during the procedure. None of the patients complained about to reach a high concentration in a short period of time,
any side effect of anesthesia or its complications. even if the settings of the vaporizer are erroneous, because
4 BioMed Research International

the concentration of the anesthetic agent is slowly increased there was no statistically significant difference between the
in the continuously breathed air in the pulmonary tract. two groups (𝑃 > 0.05). The decrease was markedly higher at
Unlike high-flow anesthesia, a careful clinical observation the 2nd hour than at the 8th and 24th hours. The causes of
may serve to determine the erroneous settings before serious a significant decrease at the 2nd postoperative hour may be
and probably dangerous changes have occurred. due to a prolonged effect of myorelaxants or recurarisation,
During low-flow anesthesia, the ventilation pressure may postoperative pain, or increased abdominal pressure due to
change. Negative pressure may occur and tidal volume may be intraoperative-caused pneumoperitoneum.
decreased. In the studies performed with low-flow anesthesia, Our facility is not enough because the study has limita-
ETCO2 was maintained between 30 and 35 mmHg. Sajedi tions. It would be useful if we had measured the gas level
et al. [14] did not find any difference in the SPO2 and ETCO2 and the heat/humidity after the “Y” piece. But we could not
values with low- and high-flow anesthesia in laparoscopic do it. If high- or low-flow anesthesia is applied properly,
cholecystectomy patients. In our patients, ETCO2 varied no different gas composition and no pressure or volume
between 26 and 40. As the change of ETCO2 did not cause changes after the “Y” piece are found. But when it is not
a change in SPO2 or any hemodynamic parameters, we did used with care, it can affect both oxygenation and ventilation
not make any changes to the tidal volume and pulmonary rate and can cause serious damage to the patient. When we
settings. use low-flow anesthesia, it can better preserve heat and
In the techniques of low-flow anesthesia, vector gases humidity compared to high-flow. This difference can impact
and volatile anesthetics are known to provide considerable on pulmonary functions as well. But this kind of harming
cost savings due to the decreased amount of wasted gas. effect needs time to be meaningful. In this study, average
In previous studies, it has been reported that 80–90% of operating time is approximately 47 min so that is enough to
anesthetic agents and gases are wasted with a flow rate of affect the pulmonary functions. Fortunately, we did not see
5 L/min [15]. the effect on pulmonary functions.
In low-flow anesthesia, it is easier to maintain the Consequently, neither the low-flow sevoflurane group
anesthetic depth previously obtained in volatile anaesthetics nor the high-flow sevoflurane group showed any significant
with low solubility, such as desflurane and sevoflurane. change in pulmonary functions postoperatively. In light
Furthermore, when high-flow is used, some issues may of these findings, we conclude that low-flow sevoflurane
be encountered with the agents that react with dry CO2 anesthesia, without any adverse effect, may be administered
absorbents, such as desflurane, enflurane, and sevoflurane for laparoscopic abdominal surgery.
[16].
The preservation of hemodynamic stability has been
proven by some researchers in recent low-flow anesthesia
Competing Interests
studies [17–19]. In our study, hemodynamic stability was pre- The authors declare that they have no competing interests.
served and no significant difference in results was observed
between the groups.
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