Desflurane (Suprane) - Uses, Dose, Side effects, MOA

Desflurane (Suprane) is an inhalational anesthetic agent used in the maintenance of general anesthesia.

Indications of Desflurane (Suprane):

Anesthesia:
- It is used for induction of anesthesia in adults and maintenance of anesthesia in adults and pediatric patients for inpatient and outpatient surgery.

Note:

Due to its irritant properties and unpleasant odor which may cause coughing, breath-holding, laryngospasm, oxygen desaturation, increased secretions, hypertension, and tachycardia, it is not suitable for induction of general anesthesia in adults.
Due to the risk of moderate to severe airway adverse effects, desflurane use for induction of anesthesia in non-intubated pediatric patients is contraindicated.
Desflurane is indicated for the maintenance of anesthesia in infants and children after induction of anesthesia with an alternate agent and tracheal intubation.

Desflurane dose in adults:

Note: Dosage must be individualized based on patient response.

Dose in the Induction of anesthesia:

Initial: Inhaled concentration of 3%, increased by 0.5% to 1% increments every 2 to 3 breaths (end-tidal concentrations 4% to 11%).
Inspired concentrations >12% have been safely administered during induction and may require a reduction of nitrous oxide or air.

Desflurane (Suprane) Dose in the maintenance of anesthesia:

Inhaled concentrations of 2.5% to 8.5% with or without concomitant nitrous oxide.

The minimum alveolar concentration (MAC), the concentration at which 50% of patients do not respond to surgical incision, varies by age. In adults, the concentration at which amnesia and loss of awareness occur (MAC - awake) is 2.4%. Surgical levels of anesthesia are maintained between 2.5% to 8.5%.

Patient Age and Minimum Alveolar Concentration (MAC)
Age	MAC with 100% Oxygen	MAC with 100% Oxygen
25y	7.3%	4%
45y	6	2.8%
70y	5.2%	1.7%
Note: Concurrent use with benzodiazepines, nitrous oxide, or opioids decreases desflurane dose. Desflurane vaporizer is heated in order to deliver a constant concentration due to high vapor pressure.

Desflurane dose in children:

Note: Dosage must be individualized based on patient response.

Desflurane (Suprane) Dose in the maintenance of anesthesia:

Children:
- Inhaled concentrations of 5.2% to 10% with or without nitrous oxide.

The minimum alveolar concentration (MAC), the concentration at which 50% of patients do not respond to surgical incision, varies by age. Surgical levels of anesthesia are maintained between 5.2% and 10% in children.

Patient Age and Minimum Alveolar Concentration (MAC)
Age	MAC with 100% Oxygen	MAC with 60% N O/40% Oxygen
9 mon	10%	7.5%
3 y	8.9%	6.4%
Note: Concurrent use with benzodiazepines, nitrous oxide, or opioids decreases desflurane dose. Desflurane vaporizer is heated in order to deliver a constant concentration due to high vapor pressure.

Desflurane (Suprane) Pregnancy Risk Category: B

Recurrent or chronic use of general anesthetics and sedation drugs can block N-methyl–D- aspartate receptors (NMDA) and/or increase gamma–aminobutyric acids (GABA) activity, causing brain damage in animal studies.
The last trimester may be the most dangerous for human fetuses.
It is important to evaluate the risks and benefits of maternal desflurane treatment during pregnancy, particularly if the procedure lasts more than three hours.
Desflurane has been used in obstetrical anesthesia.
Prefer alternative agents for anesthesia during pregnancy?
There is a risk of fetal depression and uterine relaxation in dose-dependent ways. It is important to limit maternal exposure.
ACOG recommends that pregnant women should not refuse medically-indicated surgery or procedures, regardless of which trimester.
The second trimester should be used for non-urgent procedures.
You should not elective until after delivery.

Desflurane use during breastfeeding:

It is unknown if the drug will be excreted into breast milk.
Desflurane should not be given to breastfeeding females without caution, as directed by the manufacturer.
Dependent on the pharmacokinetics, desflurane can be used to maintain anesthesia in breastfeeding women.
Elective surgery should not be performed until the child who is breastfeeding is at least two years old.
When possible, it is important to express milk before any surgery.
If the baby is healthy and full-term, breastfeeding can be resumed.
When the child is at lower risk, milk can be saved to be used later in vulnerable children.

Desflurane (Suprane) Dose adjustment in renal disease:

No dosage adjustment is necessary.

Desflurane (Suprane) Dose adjustment in liver disease:

No dosage adjustment is necessary.

Common Side Effects of Desflurane (Suprane):

Gastrointestinal:
- Nausea
- Vomiting
Respiratory:
- Cough
- Breath-holding
- Apnea

Rare Side Effects of Desflurane (Suprane):

Cardiovascular:
- Oxygen saturation decreased
- Bradycardia
- Hypertension (including malignant hypertension)
- Nodal arrhythmia
- Shivering
- Tachycardia
Central nervous system:
- Headache
Gastrointestinal:
- Sialorrhea
Ophthalmic:
- Conjunctivitis
Neuromuscular & skeletal:
- Laryngospasm
Respiratory:
- Increased bronchial secretions
- Pharyngitis

Contraindications to Desflurane (Suprane):

Hypersensitivity to desflurane or other halogenated substances, or any component in the formulation
History of mild to severe hepatic impairment after anesthesia with desflurane and other halogenated drugs. Not otherwise explained.
Patients for whom general anesthesia may be contraindicated
Induction of anesthesia for pediatric patients
Genetic susceptibility to malignant heatthermia, known or suspected

Canadian labeling: Additional contraindications not in US labeling

History of hepatitis caused by halogenated inhalational sedatives or in patients with hepatic dysfunction, jaundice, unexplained fever, or eosinophilia after previous administrations of halogenated sedatives.

Warnings and precautions

Reduced blood flow
- Desflurane can cause a decrease in renal and hepatic blood flow.
Hepatitis
- Desflurane can cause sensitive hepatitis in patients who have previously been exposed to halogenated anesthetics.
Hyperkalemia:
- Children can develop life-threatening hyperkalemia after surgery.
- Hyperkalemia can be common when succinylcholine and desflurane are used together.
- Patients with neuromuscular disease (eg Duchenne muscular dystrophy) may be at greater risk.
- Other abnormalities include myoglobinuria and elevations in CK.
- It is urgent to identify and treat hyperkalemia. Also, it is important to monitor for arrhythmias.
Increased intracranial pressure
- Desflurane can cause elevated intracranial pressure.
- Patients with intracranial space-occupying lesion should receive desflurane at a dose of =0.8 MAC.
- This should be combined with a barbiturate injection and hyperventilation during the period prior to cranial decompression.
- This will maintain cerebral perfusion pressure.
Malignant hyperthermia
- Desflurane can cause malignant hyperthermia, which could be fatal.
- It is not recommended for patients with malignant hyperthermia.
Extension of QT
- Inhalational anesthetics can prolong QT and cause fatal torsade des pointes.
- Desflurane can increase the risk of prolonging QT. This is especially true if desflurane has been used in combination with antiarrhythmic drugs class Ia and III, elderly patients, or congenital QT prolongation.
Respiratory depression
- It is possible to see dose-dependent respiratory depression as well as a blunted ventilatory response hypoxia or hypercapnia.
- The hypoxic pulmonary vasoconstriction, which is hypoxic, is reduced, resulting in an increased pulmonary shunt.
- In the presence of a desiccated drycarbon dioxide absorbent in the circle breathing system, an anesthetic machine can cause elevated carbon monoxide levels or carboxyhemoglobin.
- Barium hydroxide or soda-lime deiccation can be caused by fresh gases being passed through a carbon dioxide container at high flow rates for many hours or even days.
- According to the manufacturer fresh absorbent should always be kept regardless of the colorimetric indicator.
Cardiovascular disease
- Desflurane should not ever be used to induce anesthesia in patients suffering from coronary artery disease.
- Increases in plasma catecholamine levels can cause a sudden increase in inspired concentrations above 1 MAC. This can lead to a temporary rise in blood pressure and heart beat.
- An increase in sympathetic cardiovascular stimulation may occur from a rapid rise in desflurane levels.
- This can last for up to 4 minutes. However, it can be mitigated by concurrent use nitrous oxide and opioids, beta-blockers, alpha-2 agonists, and/or opioids.
- Hypotension due to dose-dependent hypotension may occur as a result of peripheral vasodilation. This can be treated by deepening the anesthesia.
- According to the American Heart Association, desflurane can exacerbate myocardial dysfunction.
Hepatic disease
- Hepatitis can be caused by halogenated anesthetics.
- Patients with cirrhosis, viral liver disease, and other preexisting hepatic conditions are at higher risk. Therefore, caution is advised.
- Hypersensitivity can be caused by liver dysfunction, icterus or fatal liver necrosis.
- In such situations, it is better to use alternative anesthetic agents.

Desflurane: Drug Interaction

Note: Drug Interaction Categories:

Risk Factor C: Monitor When Using Combination
Risk Factor D: Consider Treatment Modification
Risk Factor X: Avoid Concomitant Use

Risk Factor C (Monitor therapy).
Alcohol (Ethyl)	CNS Depressants can increase the CNS depressant effects of Alcohol (Ethyl).
Alfuzosin	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Alizapride	CNS Depressants may increase the CNS depressant effects.
Antipsychotic Agents, Second Generation (Atypical)	Blood Pressure Lowering Agents can increase the hypotensive effects of Antipsychotic Agents (Second Gen [Atypical]).
Barbiturates	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Benperidol	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Blood Pressure Lowering Agents	May enhance the hypotensive effect of HypotensionAssociated Agents.
Brexanolone	CNS Depressants can increase the CNS depressant effects of Brexanolone.
Brimonidine (Topical)	CNS Depressants may increase the CNS depressant effects.
Brimonidine (Topical)	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Bromopride	CNS Depressants may increase the CNS depressant effects.
Cannabidiol	CNS Depressants may increase the CNS depressant effects.
Cannabis	CNS Depressants may increase the CNS depressant effects.
Chlorphenesin Carbamate	CNS Depressants may have an adverse/toxic effect that can be exacerbated by them.
CNS Depressants	Can increase the toxic/adverse effects of CNS Depressants.
Diazoxide	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Dimethindene (Topical).	CNS Depressants may increase the CNS depressant effects.
Doxylamine	CNS Depressants may have a greater CNS depressant effect if taken with other 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	CNS Depressants may increase the CNS depressant effects.
DULoxetine	DULoxetine may increase hypotensive effects by lowering blood pressure.
EPINEPHrine (Nasal)	Inhalational anesthetics can increase the arrhythmogenic effects of EPINEPHrine.
EPINEPHrine (Oral Inhalation)	Inhalational Anesthesia may increase the arrhythmogenic effects of EPINEPHrine (Oral Inhalation).
Esketamine	CNS Depressants may increase the CNS depressant effects.
Fenoterol	Inhalational anesthetics can increase the arrhythmogenic effects of Fenoterol.
Formoterol	Formoterol's arrhythmogenic effects may be enhanced by inhalational anesthetics.
Haloperidol	QT-prolonging agents (Indeterminate risk - Caution), may increase the QTcprolonging effects of Haloperidol.
Herbs (Hypotensive properties)	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
HydrOXYzine	CNS Depressants may increase the CNS depressant effects.
Hypotension-Associated Agents	Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents.
Kava Kava	CNS Depressants may have an adverse/toxic effect that can be exacerbated by them.
Levodopa-Containing Products	Blood Pressure Lowering Agents can increase the hypotensive effects of Levodopa -Containing Products.
Lofexidine	CNS Depressants may have a greater depressant effect on the brain. Management: Separate drug interaction monographs are available for drugs listed as an exception to this monograph.
Lormetazepam	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Magnesium Sulfate	CNS Depressants may increase the CNS depressant effects.
MetyroSINE	MetyroSINE may have a sedative effect that can be enhanced by CNS depressants.
Minocycline	CNS Depressants may increase the CNS depressant effects.
Mirtazapine	CNS Depressants can increase the CNS depressant effects of Mirtazapine.
Molsidomine	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nabilone	CNS Depressants may increase the CNS depressant effects.
Naftopidil	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Neuromuscular-Blocking Agents (Nondepolarizing)	Inhalational Anesthetics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing).
Nicergoline	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nicorandil	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Nitroprusside	The hypotensive effects of Nitroprusside may be enhanced by blood pressure lowering agents.
Pentoxifylline	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Pholcodine	Pholcodine may increase hypotensive effects by lowering blood pressure.
Phosphodiesterase 5 Inhibitors	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Piribedil	CNS Depressants could increase the CNS depressant effects of Piribedil.
Pramipexole	Pramipexole may have a greater sedative effect if it is combined with CNS depressants.
Prostacyclin Analogues	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Agents that prolong QT (Highest risk)	QT-prolonging agents (Indeterminate risk - Caution), may increase the QTc prolonging effect of QT Prolonging Agents. When using these agents together, be sure to monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Quinagolide	Might increase the hypotensive effects of Blood Pressure Lowering Agents.
Ritodrine	This may increase the toxic/adverse effects of Inhalational Anesthetics.
ROPINIRole	CNS Depressants can increase the sedative effects of ROPINIRole.
Rotigotine	CNS Depressants can increase the sedative effects of Rotigotine.
Rufinamide	CNS Depressants may have an adverse/toxic effect that can be exacerbated by this. Particularly, dizziness and sleepiness may be increased.
Selective Serotonin Reuptake inhibitors	CNS Depressants can increase the toxic/adverse effects of Selective Serotonin Resuptake Inhibitors. Particularly, psychomotor impairment could be increased.
Tetrahydrocannabinol	CNS Depressants may increase the CNS depressant effects.
Tetrahydrocannabinol, and Cannabidiol	CNS Depressants may increase the CNS depressant effects.
Trimeprazine	CNS Depressants may increase the CNS depressant effects.
Risk Factor D (Consider therapy modifications)
Amifostine	Amifostine's hypotensive effects may be enhanced by blood pressure lowering agents. Treatment: Blood pressure lowering drugs should be stopped 24 hours before amifostine administration. Amifostine should be avoided if blood pressure lowering medication cannot be withheld.
Bambuterol	May increase the arrhythmogenic effects of Inhalational Anesthesthetics. Management: Some labels advise against halothane use; others suggest that you separate the administration for at least 6 hours. Other bambuterol labels don't mention any possible interactions.
Blonanserin	CNS Depressants can increase the CNS depressant effects of Blonanserin.
Buprenorphine	CNS Depressants can increase the CNS depressant effects of buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Buprenorphine patches (Butrans) should be initiated at 5 mg/hr for adults. This is when it is combined with other CNS depression drugs.
Chlormethiazole	CNS Depressants may increase the CNS depressant effects. Monitoring: Look out for signs of CNS depression. If a combination of chlormethiazole and other drugs is required, a reduced dose should be used.
Droperidol	CNS Depressants may increase the CNS depressant effects. Management: Droperidol and other CNS agents, such as opioids, may be reduced or used in combination with droperidol. Separate drug interaction monographs provide more detail on exceptions to this monograph.
EPINEPHrine (Systemic)	Systemic may have an arrhythmogenic effect from inhalational anesthetics. Patients who are currently receiving or have received inhalational anesthetics should be administered epinephrine cautiously. Monitor for cardiac arrhythmias and use lower doses than usual.
Flunitrazepam	CNS Depressants can increase the CNS depressant effects of Flunitrazepam.
HYDROcodone	CNS Depressants can increase the CNS depressant effects of HYDROcodone. When possible, avoid concomitant use with hydrocodone, benzodiazepines, or other CNS depressionants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Methotrimeprazine	Methotrimeprazine may have a higher CNS depressant activity than CNS Depressants. Methotrimeprazine can increase the CNS depressant effects of CNS Depressants. Management: Lower the adult dose of CNS Depressants by 50% and start concomitant methotrimeprazine treatment. After clinically proven efficacy of methotrimeprazine, further CNS depressant dose adjustments should only be made.
Obinutuzumab	This may increase the hypotensive effects of Blood Pressure Lowering Agents. Management: You may temporarily withhold blood pressure lowering medication beginning 12 hours before obinutuzumab injection and continuing for 1 hour after infusion.
Opioid Agonists	CNS Depressants can increase the CNS depressant effects of Opioid Aggonists. Management: When possible, avoid concomitant use opioid agonists, benzodiazepines, or other CNS depressionants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
OxyCODONE	CNS Depressants can increase OxyCODONE's CNS depressant effects. When possible, avoid the simultaneous use of oxycodone and other CNS depressants. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Perampanel	CNS Depressants may have a greater CNS depressant effect. Perampanel and any other CNS depressant drug should be used in combination. Patients who take perampanel together with other drugs that have CNS depressant activity should not engage in complex or high-risk activities until they are familiar with the combination.
Sodium Oxybate	CNS Depressants may have a greater depressant effect if taken in combination. Management: Look for alternatives to the combination use. If you must combine use, reduce the dose of any one or more drugs. It is not recommended to combine sodium oxybate and alcohol, or any sedative hypnotics.
Suvorexant	CNS Depressants can increase the CNS depressant effects of Suvorexant. Management: Suvorexant or any other CNS depressionant can be reduced in doses. Suvorexant should not be taken with alcohol. It is also not recommended to take suvorexant along with any other drugs for insomnia.
Tapentadol	CNS Depressants may increase the CNS depressant effects. Tapentadol, benzodiazepines and other CNS depressants should be avoided when possible. Combining these agents is not recommended unless there are other options. Limit the amount and duration of each drug when combined.
Zolpidem	CNS Depressants can increase the CNS depressant effects of Zolpidem. Management: For men who also take CNS depressants, reduce the adult Intermezzo brand sublingual Zolpidem dose to 1.75mg. For women, no dose adjustment is advised. Avoid using CNS depressants at night; do not use alcohol.
Risk Factor X (Avoid Combination)
Azelastine (Nasal)	CNS Depressants could increase the CNS depressant effects of Azelastine.
Bromperidol	Bromperidol's hypotensive effects may be enhanced by Blood Pressure Lowering agents. Bromperidol could decrease the hypotensive effects of Blood Pressure Lowering agents.
Bromperidol	CNS Depressants may increase the CNS depressant effects.
Dexmethylphenidate	May increase the hypertensive effects of Inhalational Anesthestics.
DOPamine	Inhalational Anesthetics can increase the arrhythmogenic effects of DOPamine. Patients receiving halogenated Hydrocarbon Anesthetics should not use dopamine. Monitor for arrhythmia if concomitant treatment is not possible. Propranolol, based on animal data, may reverse ventricular arrhythmia caused by dopamine.
Ephedra	May increase the arrhythmogenic effects of Inhalational Anesthestics.
EPHEDrine (Nasal).	May increase the arrhythmogenic effects of Inhalational Anesthestics.
EPHEDrine (Systemic)	May increase the arrhythmogenic effects of Inhalational Anesthestics.
Isoproterenol	Inhalational anesthetics can increase the arrhythmogenic effects of Isoproterenol.
Metaraminol	Metaraminol's arrhythmogenic effects may be enhanced by inhalational anesthetics.
Methylphenidate	May increase the hypertensive effects of Inhalational Anesthestics.
Norepinephrine	Inhalational anesthetics can increase the arrhythmogenic effects of Norepinephrine.
Orphenadrine	Orphenadrine may be more effective against CNS depression than other drugs.
Oxomemazine	CNS Depressants may increase the CNS depressant effects.
Paraldehyde	Paraldehyde may be enhanced by CNS depressants.
Thalidomide	CNS Depressants can increase Thalidomide's CNS depressant effects.

Monitoring parameters:

Pulse
Temperature
Blood pressure
Oxygen saturation, end-tidal CO and end-tidal desflurane concentrations should be monitored prior to and throughout anesthesia
Cardiac rhythm
Adverse respiratory symptoms in pediatric patients (≤6 years)
Signs and symptoms of airway narrowing in children with asthma or recent upper respiratory infection

How to administer Desflurane (Suprane)?

Inhalation: Via desflurane-specific calibrated heated vaporizer

Mechanism of action of Desflurane (Suprane):

Desflurane may cause general anesthesia by enhancing inhibitory postsynaptic channel activities and inhibiting excitatory synaptic activity, although this is not fully understood.

The onset of action:

1 to 2 minutes

Duration:

Emergence time: Depends on blood concentration when desflurane is discontinued
The rate of change of anesthetic concentration in the lung is more rapid with desflurane because of its low blood/gas solubility (0.42), which is similar to nitrous oxide.

Metabolism: