A comparison of postoperative respiratory complications associated with the use of desflurane and sevoflurane: a single‐centre cohort study

Abstract

Sevoflurane and desflurane are the most commonly used volatile anaesthetics for maintenance of anaesthesia. In this study, we aimed to evaluate the relationship between choice of volatile anaesthetic and early postoperative respiratory complications, and to address a critical knowledge gap in safety outcomes between these two commonly used agents. We performed a retrospective analysis of adult (non-cardiac surgery) patients who received sevoflurane or desflurane for the maintenance of general anaesthesia at our institution between 2005 and 2018. We evaluated the association between desflurane exposure (when compared with sevoflurane) and the primary outcome of postoperative respiratory complications, defined by early post-extubation desaturation (S p O 2 < 90%) or re-intubation within 7 days postoperatively. Multivariable regression analyses were performed and adjusted for confounding factors, including patient, anaesthetic and surgical factors. Propensity matched, interaction and subgroup analyses were performed to assess outcomes in high-risk groups: morbidly obese (BMI > 35 kg.m À2); elderly (age > 65 years); and high risk of respiratory complications as well as the primary outcome at 24 h. Desflurane was used for 23,830 patients and sevoflurane for 84,608 patients. Patients exposed to desflurane did not demonstrate a reduced risk of postoperative respiratory complications when compared with sevoflurane (adjusted odds ratio 0.99, 95%CI 0.94-1.04, p = 0.598). These findings were consistent across all subgroups of high-risk patients and in the propensity score matched cohort. In summary, desflurane use was not associated with reduced postoperative respiratory complications when compared with sevoflurane. In the context of environmental and cost concerns with volatile anaesthetic agents, our study provides important data to support organisational decisions regarding the use of desflurane.

Desflurane in modern anaesthetic practice: walking on thin ice(caps)?

“…A recent observational study of over 100,000 cases by Zucco and colleagues, for example, found no difference in postoperative pulmonary complications between patients anaesthetised with sevoflurane and desflurane when adjusted for confounding factors. 8 One potential advantage of desflurane is the faster time to recovery of consciousness and tracheal extubation. However, whilst meta-analyses of randomised controlled trials (RCTs) have confirmed that this is consistently a statistically significant finding (table 1), the magnitude of this effect is minimal (only a few minutes in most circumstances), and it does not appear that this translates to shorter patient stays in the post-anaesthesia care unit (PACU).…”

“…However, whilst meta-analyses of randomised controlled trials (RCTs) have confirmed that this is consistently a statistically significant finding (table 1), the magnitude of this effect is minimal (only a few minutes in most circumstances), and it does not appear that this translates to shorter patient stays in the post-anaesthesia care unit (PACU). [8][9][10][11][12]14 Furthermore, as pointed out by Macario and colleagues, because RCT study protocols tend to require the use of a constant concentration of general anaesthetic agent up to the point of wound closure, the common clinical practice of tapering the anaesthetic dose as the surgical stimulus reduces is not represented, and this may further reduce any 'real world' difference between agents. 10 We contend that a trivially more rapid emergence from general anaesthesia with desflurane compared to sevoflurane may be of greater promotional benefit to the manufacturer than either clinical benefit to the patient or organisational benefit to surgical operating efficiency.…”

“…Here, there is little evidence of any benefit to desflurane, and the degree of hypotension demonstrated in Ryu's study is a cause for concern, particularly in older or comorbid patients. [8][9][10][11][12][13][14][15] In terms of quality of care, desflurane is consistently associated with more rapid emergence from anaesthesia and tracheal extubation, however these benefits are small in magnitude and do not lead to any improvement in discharge times. [8][9][10][11][12]14 As a consequence, these benefits are likely to be noticed only by the anaesthetic team, but not by the patient or operating theatre staff more generally.…”

“…[8][9][10][11][12][13][14][15] In terms of quality of care, desflurane is consistently associated with more rapid emergence from anaesthesia and tracheal extubation, however these benefits are small in magnitude and do not lead to any improvement in discharge times. [8][9][10][11][12]14 As a consequence, these benefits are likely to be noticed only by the anaesthetic team, but not by the patient or operating theatre staff more generally. Although patient outcomes are of paramount importance for the anaesthetist, this does not mean that the effects of climate change on communities worldwide should be discounted.…”

“…21,25 Ryu et al's study in this issue of the British Journal of Anaesthesia adds to existing evidence aligning these two responsibilities through the discontinuation of desflurane use and manufacture. 8,15 Individual anaesthetists, as well as the wider profession, can choose how to deliver general anaesthesia. We accept that inhalational anaesthetic agents may be appropriate in certain circumstances, but assumptions about the specific clinical benefits of desflurane based on its physiochemical properties are breaking down.…”