Anästhesie und klinische Forschung
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Abstrakt

Inhaled Desflurane vs. Propofol for Postoperative Sedation Guided with Patient State Index of SEDline in Mechanically Ventilated Liver Transplant Recipient

Khaled Ahmed Yassen, Eman Kamal EL-Deen Awaad, Emad Kamel Refaat, Neveen Mostafa Soliman and Magda Fouad Yehia

Background: Monitoring sedation depth with appropriate sedative choice can reduce over sedation and associated side effects. Objectives: To compare Desflurane (Des) vs. Propofol (P) sedation with regards to, haemodynamics, recovery profiles, side effects and costs. Design: A prospective randomized hospital based comparative study. Setting: In a single centre between May 2012 and December 2014. Patients: Sixty mechanically ventilated liver recipients were assigned randomly to receive postoperative sedation either with inhalational Des in air/oxygen 1 litre min-1 or intravenous P 4 mg/kg/hr. Interventions: Recovery time and response to eye opening was recorded. Memorization of five words, Trieger dot test, and digit symbol substitution tests were applied. The Patient State Index (PSI) by SEDLine Sedation Monitor (Masimo, Irvin, CA) was used to target adequate depth of sedation (50-75) in both groups. Ramsay sedation score (RSS) was monitored. Fentanyl was used to assist sedation guided with PSI. The Transesophageal Doppler (TED) was recorded hourly; corrected flow time (FTc) of TED was used for fluid optimization. Main outcome measures: Recovery profile was the primary end point.Secondary outcomes were haemodynamic events, side effects and cost.   Recovery was faster with Desflurane than Propofol (2.0+1.1 vs. 13.1+4.4 min, P<0.01, respectively) regarding eye opening (PSI>75), five words recall, trieger dot test and digit symbol substitution test. Required duration of sedation was lower with Desflurane (6.83 ± 2.00 vs. 8.26 ± 1.68 hour, P=0.004). Systemic vascular resistance (SVR) and mean arterial blood pressure (MABP) were better maintained with Desflurane. Under comparable PSI readings between both groups at all measuring points (SVR, MABP and PSI after 2hrs sedation 908.93 ± 139.5 vs. 617.6 ± 104.5 dyn.sec.cm-5, P<0.01 and 77.0 ± 3.8 vs. 63.4 ± 6.3 mmHg, P<0.01, 63.30 ± 6.374 vs. 62.2 ± 5.8, P=0.517 respectively), in contrast the mean RSS was consistently higher with Des compared to P, P<0.01 at all times. Less norepinephrine was required with Des (n=10) (33.3%) compared to P (n=23) (76.7%), (P=0.001). Ventilation duration shortened with Des vs, P (6.83 ± 2.00 vs. 8.26 ± 1.68 hour, P=0.004) with comparable arterial blood gases at start (P>0.01). Fentanyl was frequently combined with P to reduce its effect on SVR and MBP. (483.3+168.3 vs. 100 ± 0.00 μg, P<0.05). Total consumption of Des and P were (53.13 ± 10.30 ml vs. 1010.33 ± 205.06 mg). Cost was lower with Desflurane (0.9+0.3 vs. 1.6+0.4) Sterling £/hour, (P=0.000). Conclusion: Postoperative Desflurane sedation guided with PSI enhanced recovery at a lower cost when compared to Propofol as well as preserving better the haemodynamics at a lower cost.