JOURNAL OF EVIDENCE BASED MEDICINE AND HEALTHCARE

Table of Contents

2019 Month : October Volume : 6 Issue : 43 Page : 2824-2827

Comparison of haemodynamic and Recovery Profile Using Propofol and Sevoflurane for Otorhinolaryngology Procedures

Siri Kandavar1, Padmanabha Sampathila2

1. Assistant Professor, Department of Anaesthesiology, K. S. Hegde Medical Academy, Karnataka.
2. Professor, Department of Anaesthesiology, Yenepoya Medical College, Karnataka.



Corresponding Author:
Dr. Siri Kandavar,
Assistant Professor,
Department of Anaesthesiology,
K. S. Hegde Medical Academy,
Deralakatte, Mangalore, Karnataka.
E-mail: sirikandavar16@gmail.com
DOI: 10.18410/jebmh/2019/586

 

ABSTRACT
BACKGROUND
Induction and maintenance of general anaesthesia is done with both intravenous and inhalational agents. This observational study was conducted to compare haemodynamic and recovery profile using propofol and sevoflurane for maintenance of anaesthesia. We wanted to compare haemodynamic parameters like heart rate and mean arterial pressure of sevoflurane and propofol.

METHODS
We included 64 adult patients, belonging to ASA I and II, coming for otorhinolaryngology procedures. They were allocated into 2 groups using closed envelope method. Both groups were induced with propofol 2 mg/Kg, fentanyl 2 mcg/Kg and vecuronium 0.1 mg/Kg and intubated with appropriately sized endotracheal tube. After confirmation of endotracheal tube, oxygen 50% and nitrous oxide 50% and propofol at 100-200 mcg/Kg or sevoflurane at 1.5-2% was started. haemodynamic changes like heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were recorded from the beginning till the end of the procedure. Haemodynamic profile was noted at the time of extubation and 5 minutes after extubation. Time taken for extubation and spontaneous eye opening were also noted. Post-operative nausea and vomiting (PONV) were looked for in immediate postoperative period and after 4 hours.

RESULTS
In the study, propofol group had lower heart rate compared to sevoflurane group which was statistically significant (p= 0.0001). Mean arterial pressure was also lower in the propofol compared to sevoflurane group and was statistically significant (p= 0.0001). Recovery profile was similar in both groups which was not statistically significant. Post-operative nausea and vomiting were seen in both groups in the immediate post-operative period. PONV was noted in 37.5% patients in sevoflurane group and 6.75% in propofol group but it was not seen in propofol group after four hours.

CONCLUSIONS
We found that propofol which was used for maintenance of anaesthesia had better haemodynamic stability compared to sevoflurane; but the time taken for extubation and recovery was similar in both groups. PONV was noted in both the groups but was lesser in propofol group.

KEYWORDS
Inhalational Anaesthesia, Intravenous Anaesthesia, Propofol, Sevoflurane, Post-Operative Nausea and Vomiting

How to cite this article

Kandavar S, Sampathila P. Comparison of haemodynamic and recovery profile using propofol and sevoflurane for otorhinolaryngology procedures. J. Evid. Based Med. Healthc. 2019; 6(43), 2824-2827. DOI: 10.18410/jebmh/2019/586

BACKGROUND

Inhalational and intravenous anaesthetic agents are used for induction and maintenance of anaesthesia. Both agents provide good haemodynamic stability and has been used for maintenance of anaesthesia. The use of newer anaesthetic agents like sevoflurane and propofol has made fast tracking in anaesthesia and early ambulation possible. Using total intravenous anesthesia has advantages over inhalational anaesthesia. It is associated with lower post-operative nausea and vomiting, avoids risk of malignant hyperthermia, reduces operating room pollution and has less effect on environment pollution and greenhouse effect.1 Sevoflurane due to its low blood gas partition coefficient has fast induction and rapid recovery from anaesthesia. Propofol is a rapidly acting intravenous drug with a very short half-life. Induction and recovery from anaesthesia is very smooth without any emergence.1

Otorhinolaryngology surgical procedures are microscopic procedures which requires good haemodynamic stability and blood less field for surgery. Propofol and sevoflurane are known to provide good haemodynamic stability.2 In this prospective randomized observational study, we are comparing propofol and sevoflurane for maintaining anaesthesia during intra-operative period and its recovery profile.

METHODS

This prospective randomized observational study was done over a period of 2 years in department of Anaesthesiology. After institutional ethical committee clearance and written and informed consent from the patient for the study, patients were allocated into 2 groups. A total of 64 patients were included in this study belonging to ASA I and II undergoing otorhinolaryngology procedures under general anaesthesia electively. The study population were randomly divided into two groups using closed envelope method. Group P patients received propofol for maintenance of anaesthesia and Group S received sevoflurane for maintenance of anaesthesia.

All the patients included in the study were kept fasting from midnight and premedication alprazolam 0.25mg orally was given night and on the day of surgery. On the day of surgery, after confirming fasting status, patients were shifted to operating room, intravenous line was secured, and intravenous fluids were started. Routine monitors like electrocardiogram (ECG), noninvasive blood pressure (NIBP) monitoring and plethysmography probe (SPO2) were attached and baseline vitals noted. Patients were then induced with fentanyl 2 mcg/Kg, propofol 2 mg/Kg and vecuronium 0.1mg/Kg was given after checking for adequate bag mask ventilation. All patients were intubated after 3 minutes of bag and mask ventilation. Maintenance of anaesthesia was done with oxygen 50% and nitrous oxide 50% and either propofol at 100-200 mcg/Kg or sevoflurane at 1-2% was started in respective group. Maintenance anaesthetic agents were discontinued at the time of skin incision. Intraoperative heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were monitored. Patient’s vitals for the study were taken from starting of propofol or sevoflurane till two hours. All the patients were monitored for time taken to spontaneous eye opening and time taken to extubate from stopping of anaesthetic agents. If patients had any post-operative nausea and vomiting, it was noted immediately in the post-operative period and also after four hours.

Data was analysed using SPSS software version 20. Statistical analysis used for the data were mean with standard deviation and student t test for individual samples among groups. For categorical data, Fisher’s, exact test was applied. Mann- Whitney test was used for non - parametric data. P value of <0.05 was considered as statistically significant.

RESULTS

In the study, 64 patients were included with 32 in each group. Demographic characteristics were comparable in the study groups. The mean age in group P was 29.69 (6.97) years and group S was 29.20(6.64) years which was comparable between the group as seen in table 1. The duration of anaesthesia was comparable in both groups which was around 135.46(6.48) minutes in group P and 133.37(5.36) minutes in group S which was not statistically significant.

 

Demographic Variables

Group P

(n=32)

Group S (n=32)

p

Age (years)

29.69(6.97)

29.20(6.64)

0.774

Weight (Kg)

57.83(9.48)

56.29(8.48)

0.496

Duration of anaesthesia

135.46(6.48)

133.37(5.36)

0.1647

Table 1. Demographic Variables of the Two Groups

 

Hemodynamic parameters like heart rate and non-invasive blood pressure were noted from the beginning till two hours which was comparable in both groups. There was difference in heart rate in two groups which was statistically significant as seen in table 2. The heart rate during the maintenance phase was lower in group P. The lowest mean heart rate noted in group P was 76.94(6.571) at 1 min and 86.46(7.425) in sevoflurane group at 60th min.

 

Heart Rate

Group P

Group S

p-Value

Baseline

90.60(11.900)

89.71(11.744)

0.1930

Induction

82.34(8.033)

90.16(11.744)

0.0028

Post intubation

79.89(7.078)

85.97(13.457)

0.0272

1 min

76.94(6.571)

86.66(12.948)

0.0003

5 min

80.66(6.412)

94.86(9.331)

0.0001

10 min

80.26(6.171)

93.34(9.117)

0.0001

15 min

80.29(5.539)

88.40(9.159)

0.0001

30 min

80.51(4.973)

86.69(8.801)

0.0010

45 min

79.51(4.461)

88.51(7.931)

0.0001

60 min

82.65(5.675)

86.46(7.425)

0.0245

90 min

80.48(5.635)

87.23(5.429)

0.0001

120 min

79.43(7.724)

87.00(10.101)

0.0013

Post extubation 1 min.

95.76(6.893)

105.32(9.965)

0.0001

5 min.

80.67(4.827)

92.48(8.632)

0.0001

 

Mean Arterial Pressure

Group P

Group S

p Value

Base line

82.75(7.394)

84.98(8.967)

0.218

Induction

78.17(6.327)

92.80(9.181)

0.0001

Post intubation

78.77(6.236)

91.94(9.115)

0.0001

1 min.

78.45(6.303)

92.45(8.958)

0.0001

5 min.

78.08(6.298)

92.85(9.115)

0.0001

10 min.

78.17(6.327)

92.80(8.967)

0.0001

15 min.

78.45(7.502)

92.45(9.115)

0.0001

30 min.

78.17(5.385)

92.80(8.792)

0.0001

45 min.

78.17(6.938)

92.80(9.286)

0.0001

60 min.

78.45(6.549)

92.45(8.471)

0.0001

90 min.

78.45(7.491)

92.45(7.693)

0.0001

120 min.

79.49(7.693)

87.39(8.469)

0.0002

Table 2. Comparison of Heart Rate Between the Groups from Induction till Post-Extubation

 

There is a difference in mean blood pressure between the two groups which was statistically significant. The mean blood pressure was lower in Group P than in Group S which was statistically significant as seen in table 3.

 

Post Extubation

Group P

Group S

p Value

1 min.

83.72(6.928)

96.36(4.304)

0.0001

5 min.

79.38(7.284)

95.87(6.836)

0.0001

Table 3. Comparison of Mean Arterial Pressure Between the Groups from Induction till Post-Extubation

 

The mean time taken to extubate in group P is 8.29 (4.397) min which was lower than time taken to extubate in group S that is 10.57(3.642) min but not statistically significant as seen in table 4.

 

Parameters

Group P

Group S

p Value

Time to extubate (min)

8.29(4.397)

10.57(3.642)

0.0274

Spontaneous eye opening (min)

12.45(4.654)

14.48(5.328)

0.1096

Table 4. Time Taken for Extubation and Recovery

 

There was post-operative nausea and vomiting in both groups but was higher in group S (37.5%), After four hours, no patients had post-operative nausea and vomiting in group P as seen in table 5 but 8 (25%) patients had PONV in sevoflurane group.

 

Post-Operative Nausea and Vomiting

Group P

Group S

Within 1 hour

2(6.25%)

12(37.5%)

Within 4 hours

nil

8(25%)

Table 5. PONV between the Groups

 DISCUSSION

Maintenance of anaesthesia can be done with inhalational and intravenous agents. Inhalational agents like sevoflurane has low blood gas partition coefficient causing quick induction and also rapid emergence and recovery.3 Propofol, a non-barbiturate intravenous agent, has rapid onset and short half-life. It reduces heart rate and mean arterial pressure and has rapid recovery making it a good choice even for maintenance of anaesthesia.

This study was conducted to compare haemodynamics and recovery profile between propofol and sevoflurane when used for maintenance of anaesthesia. In our study, heart rate was lower and more stable in propofol group than in sevoflurane group. Mean arterial pressure was also lower in the propofol group compared to the sevoflurane group. Time taken for extubation and spontaneous eye opening was similar in both groups which was statistically insignificant. Post-operative nausea and vomiting was higher in sevoflurane group.

Induction of anaesthesia with propofol is associated with fall in heart rate and blood pressure. This occurs due to decrease in systemic vascular resistance and cardiac output. It also reduces cardiac sympathetic activity which further reduces the heart rate.4,5,6 Kanaya et al studied differential effect of sevoflurane and propofol on heart rate variability. Propofol reduced cardiac sympathetic tone depending on the level of hypnosis whereas sevoflurane has little action on the sympathetic tone of heart.7 Sato et al conducted a study on baro-reflex control of heart rate before and after propofol infusion. They noted blunting of cardiac baro-reflex responses during propofol anaesthesia at a calculated blood concentration of 5mg/ml in healthy humans.8 Sevoflurane also has effect on the heart rate and baro-reflex response but in a very dose dependent manner. In our study we found heart rate in propofol was close to resting heart rate whereas sevoflurane group had slightly higher heart rate compared to propofol group.

Propofol reduces the mean arterial pressure by 15–30% during induction by reducing the systemic vascular resistance.9 It also has direct arteriolar effect which reduces the arterial blood pressure. In a study done by Husedzinovi et al, they compared the effect of sevoflurane and propofol anaesthesia on myocardial contractility using transoesophageal echocardiogram. They found that stroke volume was significantly higher in the sevoflurane than in the propofol group after induction of anaesthesia.10

Emergency agitation is a known side effect of sevoflurane which is commonly seen in children during recovery phase of anaesthesia.11 Sudden removal of anaesthetic agent with low blood gas solubility coefficient can lead to emergence.11 Godet et al in a study said that recovery profile was similar with both propofol and sevoflurane but emergence reaction was seen more with sevoflurane.12 We did not see any emergence in our study groups.

Fish, Hobbs and Daniel studied total intravenous anaesthesia using propofol and remifentanil and inhalational anaesthesia using sevoflurane and alfentanil in patients coming for day care urological surgery.13 They noted rapid recovery and street fitness with both propofol and sevoflurane. In our study recovery time for both propofol and sevoflurane group was the same and there was no statistical difference between the groups. Singh SK et al compared recovery profile between sevoflurane and propofol anaesthesia. They did not find any significant difference between the groups with regard to recovery and emergence during recovery.14

Postoperative nausea and vomiting is one of the complications of general anaesthesia. It is associated with factors like inhalational agents, use of opioids, female gender, type of surgery and many other factors. Since our study was among ENT surgical population who are more prone for nausea and vomiting, we noted whether patients had nausea and vomiting in the postoperative period. Despite giving antiemetic agent like ondansetron during intraoperative period we noted nausea and vomiting in both groups. In between the groups, percentage of nausea and vomiting was higher in sevoflurane group than in propofol group. Singh SK said postoperative nausea and vomiting remains major complaints that affects patient’s overall satisfaction after anaesthesia.15 Lee et al, compared total intravenous anaesthesia with propofol and balanced anaesthesia with sevoflurane and remifentanil undergoing mastoidectomy and tympanoplasty. They studied the incidence and severity of post-operative nausea and vomiting. They found the severity of nausea and vomiting was lesser in propofol group.16,17 We also noted post-operative nausea and vomiting in both groups but was lesser in propofol group.

CONCLUSIONS

Propofol has better haemodynamic stability during maintenance phase of anaesthesia. The recovery profile with both sevoflurane and propofol group were same with no emergence agitation. Post-operative nausea and vomiting was seen in both the groups but lesser in propofol group.

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