Sevoflurane is an inhalational anesthetic that is used in the induction and maintenance of general anesthesia.
Sevoflurane Uses:
-
Anesthesia:
- Used for induction and maintenance of general anesthesia in adults and pediatric patients for both inpatient and outpatient surgery
Sevoflurane Dose in Adults
Sevoflurane Dose in Anesthesia:
-
Inhalation:
- Concentrations from 0.5% to 3% are generally required to achieve the surgical levels of anesthesia with or without the concomitant use of nitrous oxide; 0.6% is the concentration at which amnesia and loss of awareness occur.
-
MAC values for surgical levels of anesthesia:
-
25 years:
- Sevoflurane in oxygen: 2.6%
- Sevoflurane in 65% N 0/35% oxygen: 1.4%
-
40 years:
- Sevoflurane in oxygen: 2.1%
- Sevoflurane in 65% N 0/35% oxygen: 1.1%
-
60 years:
- Sevoflurane in oxygen: 1.7%
- Sevoflurane in 65% N 0/35% oxygen: 0.9%
-
80 years:
- Sevoflurane in oxygen: 1.4%
- Sevoflurane in 65% N 0/35% oxygen: 0.7%
-
Sevoflurane Dose in Childrens
Sevoflurane Dose in Anesthesia:
-
Inhalation:
- Concentrations from 0.5% to 3% are generally required to achieve the surgical levels of anesthesia with or without the concomitant use of nitrous oxide; 0.6% is the concentration at which amnesia and loss of awareness occur.
-
MAC values for surgical levels of anesthesia:
-
0 to 1-month-old full-term neonates:
- Sevoflurane in oxygen: 3.3%
-
1 to <6 months:
- Sevoflurane in oxygen: 3%
-
6 months to <1 year:
- Sevoflurane in oxygen: 2.8%
- Sevoflurane in 65% N 0/35% oxygen: 2%
-
1 to <3 years:
- Sevoflurane in oxygen: 2.8%
- Sevoflurane in 60% N 0/40% oxygen: 2%
-
3 to 12 years:
- Sevoflurane in oxygen: 2.5%
-
Pregnancy Risk Category: B
- It can also cross the placenta.
- Data from animal studies show that brain development can be affected by prolonged or repeated use of general anesthetics and sedation medication that block N-methyl D- aspartate receptors (NMDA) and/or inhibit gamma-aminobutyric Acid (GABA). Human fetuses are most at risk in the 3rd trimester.
- It is important to evaluate the risks and benefits of sevoflurane treatment for mothers during pregnancy, particularly for procedures lasting more than three hours.
- It has been reported that Sevoflurane can be used in obstetrical anesthesia.
- Avoiding maternal exposure is important as it can cause uterine relaxation and fetal depress. There have been no adverse reactions to general anesthesia used for elective c section delivery.
- ACOG recommends that pregnant women not refuse medically-indicated surgery or procedures, regardless of their trimester.
- Non-urgent surgery should not be performed during the second trimester. Avoid elective surgery until after delivery.
Use while breastfeeding
- It is unknown if Sevoflurane is present in breast milk. However, it is quickly washed out so its levels are unlikely to be of any clinical significance 1 day after anesthesia.
- The Academy of Breast Feeding Medicine recommends postponing elective surgery until your child is more mature and established in breastfeeding.
- When possible, express milk should be used before surgery.
- A healthy, full-term baby can resume breastfeeding or express milk once she is awake and well.
- Save milk for vulnerable children to use later when they are at lower risk.
Dose in Kidney Disease:
No dosage adjustments have been provided in the manufacturer's labeling; use cautiously in patients with creatinine >1.5 mg/dL (safety not established).
Dose in Liver disease:
No dosage adjustments have been provided in the manufacturer's labeling; use cautiously. The safety in patients with severe hepatic impairment has not been studied
Common Side Effects of Sevoflurane:
-
Cardiovascular:
- Hypotension
-
Central Nervous System:
- Agitation
-
Gastrointestinal:
- Nausea
- Vomiting
-
Respiratory:
- Cough
Less Common Side Effects of Sevoflurane:
-
Cardiovascular:
- Tachycardia
- Bradycardia
- Hypertension
-
Central Nervous System:
- Drowsiness
- Shivering
- Dizziness
- Headache
- Hypothermia
- Myoclonus
- Delirium
-
Gastrointestinal:
- Sialorrhea
-
Respiratory:
- Airway Obstruction
- Laryngospasm
- Breath-Holding
- Apnea
-
Miscellaneous:
- Fever
Contraindications to Sevoflurane:
- Hypersensitivity to sevoflurane or other halogenated painkillers, or any component in the formulation
- Malignant hyperthermia susceptibility (known or suspected).
Canadian labeling: Additional contraindications not in US labeling
- Previous administrations of halogenated anesthetics have caused liver dysfunction, jaundice or unexplained febrile illness, such as leukocytosis or eosinophilia.
- Contraindications to general anesthesia
Warnings and precautions
-
Agitation/delirium
- You should monitor for any emergence agitation, delirium or other symptoms.
-
Hepatic effects
- Rarely, hepatitis post-operatively or hepatic dysfunction may occur with or without jaundice. The risk of developing a halogenated hydrocarbon anesthetic reaction is higher if you have had previous exposure.
-
Hyperkalemia
- Rare cases of perioperative hyperkalemia have been reported in pediatric patients. The use of inhaled anesthetics has been used in a few cases, but not all.
- Latent and overt neuromuscular diseases (eg Duchenne muscular dystrophy) were the most vulnerable. Other abnormalities include elevated CPK or myoglobinuria. Monitor closely for arrhythmias. Recognize and treat hyperkalemia and resistive arrhythmias immediately.
-
Hypotension
- A dose-dependent decrease in blood pressure can occur during maintenance anesthesia. This may be more rapid than other inhaled anesthetics.
-
Increased intracranial pressure
- Vasodilation of the cerebral vasculature may occur, and in some cases, it may raise intracranial pressure.
-
Malignant hyperthermia
- Malignant hyperthermia can be triggered. Some fatal cases have been reported. Patients with certain inherited mutations in the ryanodine receptor are not recommended to use this product.
-
Extension of QT
- QT prolongation has been associated with sevoflurane in some cases (some fatal). Use caution in patients at high risk for QT prolongation.
-
Respiratory depression
- It is possible to develop dose-dependent respiratory depression, blunted ventilatory responses to hypoxia or hypercapnia, and dose-dependent respiratory depression. This can cause a decrease in hypoxic pulmonary vasoconstriction, which can lead to an increase in pulmonary shunt.
-
Heart Failure:
- The American Heart Association has stated that sevoflurane may be an agent that can exacerbate myocardial dysfunction.
-
Hepatic impairment
- Patients with severe hepatic impairment should be cautious. It is not known if the drug is safe in patients with severe liver impairment.
-
Renal impairment
- Patients with kidney impairment (ie creatinine >1.5 mg/dL) should be cautious.
- It has not been proven safe for patients with severe renal impairment.
-
Seizure disorder
- Patients at high risk of seizures should be treated with caution Children and young adults may experience seizures.
Sevoflurane: Drug Interaction
|
Alcohol (Ethyl) |
CNS Depressants may enhance the CNS depressant effect of Alcohol (Ethyl). |
|
Alfuzosin |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Alizapride |
May enhance the CNS depressant effect of CNS Depressants. |
|
Antipsychotic Agents (Second Generation [Atypical]) |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). |
|
Barbiturates |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Benperidol |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Blood Pressure Lowering Agents |
May enhance the hypotensive effect of Hypotension-Associated Agents. |
|
Brexanolone |
CNS Depressants may enhance the CNS depressant effect of Brexanolone. |
|
Brimonidine (Topical) |
May enhance the CNS depressant effect of CNS Depressants. |
|
Brimonidine (Topical) |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Bromopride |
May enhance the CNS depressant effect of CNS Depressants. |
|
Cannabidiol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Cannabis |
May enhance the CNS depressant effect of CNS Depressants. |
|
Chlorphenesin Carbamate |
May enhance the adverse/toxic effect of CNS Depressants. |
|
CNS Depressants |
May enhance the adverse/toxic effect of other CNS Depressants. |
|
Diazoxide |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Dimethindene (Topical) |
May enhance the CNS depressant effect of CNS Depressants. |
|
Doxylamine |
May enhance the CNS depressant effect of 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 |
May enhance the CNS depressant effect of CNS Depressants. |
|
DULoxetine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. |
|
EPINEPHrine (Nasal) |
Inhalational Anesthetics may enhance the arrhythmogenic effect of EPINEPHrine (Nasal). |
|
EPINEPHrine (Oral Inhalation) |
Inhalational Anesthetics may enhance the arrhythmogenic effect of EPINEPHrine (Oral Inhalation). |
|
Esketamine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Fenoterol |
Inhalational Anesthetics may enhance the arrhythmogenic effect of Fenoterol. |
|
Formoterol |
Inhalational Anesthetics may enhance the arrhythmogenic effect of Formoterol. |
|
Haloperidol |
QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTcprolonging effect of Haloperidol. |
|
Herbs (Hypotensive Properties) |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
HydrOXYzine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Hypotension-Associated Agents |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. |
|
Isoniazid |
May decrease the serum concentration of CYP2E1 Substrates (High risk with Inhibitors). Specifically, it may decrease CYP2E1 substrate serum concentrations below baseline after isoniazid discontinuation. Isoniazid may increase the serum concentration of CYP2E1 Substrates (High risk with Inhibitors). |
|
Kava Kava |
May enhance the adverse/toxic effect of CNS Depressants. |
|
Levodopa-Containing Products |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products. |
|
Lofexidine |
May enhance the CNS depressant effect of CNS Depressants. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs. |
|
Lormetazepam |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Magnesium Sulfate |
May enhance the CNS depressant effect of CNS Depressants. |
|
MetyroSINE |
CNS Depressants may enhance the sedative effect of MetyroSINE. |
|
Minocycline |
May enhance the CNS depressant effect of CNS Depressants. |
|
Mirtazapine |
CNS Depressants may enhance the CNS depressant effect of Mirtazapine. |
|
Molsidomine |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nabilone |
May enhance the CNS depressant effect of CNS Depressants. |
|
Naftopidil |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Neuromuscular-Blocking Agents (Nondepolarizing) |
Inhalational Anesthetics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). |
|
Nicergoline |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nicorandil |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Nitroprusside |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. |
|
Pentoxifylline |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Pholcodine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. |
|
Phosphodiesterase 5 Inhibitors |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Piribedil |
CNS Depressants may enhance the CNS depressant effect of Piribedil. |
|
Pramipexole |
CNS Depressants may enhance the sedative effect of Pramipexole. |
|
Prostacyclin Analogues |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
QT-prolonging Agents (Highest Risk) |
QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. |
|
Quinagolide |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. |
|
Ritodrine |
May enhance the adverse/toxic effect of Inhalational Anesthetics. |
|
ROPINIRole |
CNS Depressants may enhance the sedative effect of ROPINIRole. |
|
Rotigotine |
CNS Depressants may enhance the sedative effect of Rotigotine. |
|
Rufinamide |
May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. |
|
Selective Serotonin Reuptake Inhibitors |
CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. |
|
Tetrahydrocannabinol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Tetrahydrocannabinol and Cannabidiol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Trimeprazine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Risk Factor D (Consider therapy modification) |
|
|
Amifostine |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. |
|
Bambuterol |
|
|
Blonanserin |
CNS Depressants may enhance the CNS depressant effect of Blonanserin. |
|
Buprenorphine |
CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. |
|
Chlormethiazole |
May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. |
|
CYP2E1 Inhibitors (Strong) |
May decrease the metabolism of CYP2E1 Substrates (High risk with Inhibitors). |
|
Droperidol |
May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Exceptions to this monograph are discussed in further detail in separate drug interaction monographs. |
|
EPINEPHrine (Systemic) |
Inhalational Anesthetics may enhance the arrhythmogenic effect of EPINEPHrine (Systemic). Management: Administer epinephrine with added caution in patients receiving, or who have recently received, inhalational anesthetics. Use lower than normal doses of epinephrine and monitor for the development of cardiac arrhythmias. |
|
Flunitrazepam |
CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. |
|
HYDROcodone |
CNS Depressants may enhance the CNS depressant effect of HYDROcodone. Management: Avoid concomitant use of hydrocodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Methotrimeprazine |
CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce adult dose of CNS depressant agents by 50% with initiation of concomitant methotrimeprazine therapy. Further CNS depressant dosage adjustments should be initiated only after clinically effective methotrimeprazine dose is established. |
|
Obinutuzumab |
May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. |
|
Opioid Agonists |
CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
OxyCODONE |
CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Perampanel |
May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. |
|
Sodium Oxybate |
May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to combined use. When combined use is needed, consider minimizing doses of one or more drugs. Use of sodium oxybate with alcohol or sedative hypnotics is contraindicated. |
|
Suvorexant |
CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. |
|
Tapentadol |
May enhance the CNS depressant effect of CNS Depressants. Management: Avoid concomitant use of tapentadol and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. |
|
Zolpidem |
CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. |
|
Risk Factor X (Avoid combination) |
|
|
Azelastine (Nasal) |
CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal). |
|
Bromperidol |
Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents. |
|
Bromperidol |
May enhance the CNS depressant effect of CNS Depressants. |
|
Dexmethylphenidate |
May enhance the hypertensive effect of Inhalational Anesthetics. |
|
DOPamine |
Inhalational Anesthetics may enhance the arrhythmogenic effect of DOPamine. Management: Avoid use of dopamine in patients receiving halogenated hydrocarbon anesthetics. If concomitant treatment cannot be avoided, monitor for arrhythmia. Dopamine induced ventricular arrhythmia may be reversible with propranolol based on animal data. |
|
Ephedra |
May enhance the arrhythmogenic effect of Inhalational Anesthetics. |
|
EPHEDrine (Nasal) |
May enhance the arrhythmogenic effect of Inhalational Anesthetics. |
|
EPHEDrine (Systemic) |
May enhance the arrhythmogenic effect of Inhalational Anesthetics. |
|
Isoproterenol |
Inhalational Anesthetics may enhance the arrhythmogenic effect of Isoproterenol. |
|
Metaraminol |
Inhalational Anesthetics may enhance the arrhythmogenic effect of Metaraminol. |
|
Methylphenidate |
May enhance the hypertensive effect of Inhalational Anesthetics. |
|
Norepinephrine |
Inhalational Anesthetics may enhance the arrhythmogenic effect of Norepinephrine. |
|
Orphenadrine |
CNS Depressants may enhance the CNS depressant effect of Orphenadrine. |
|
Oxomemazine |
May enhance the CNS depressant effect of CNS Depressants. |
|
Paraldehyde |
CNS Depressants may enhance the CNS depressant effect of Paraldehyde. |
|
Thalidomide |
CNS Depressants may enhance the CNS depressant effect of Thalidomide. |
Monitoring parameters:
- Blood pressure
- Temperature,
- Heart rate and rhythm
- O2 saturation
- Monitor end-tidal CO2 and end-tidal sevoflurane concentrations prior to and throughout anesthesia
- The temperature of CO2 absorbent canister
How to administer Sevoflurane?
Sevoflurane-specific calibrated vaporizers are used to administer; use with caution in low-flow or closed-circuit systems since sevoflurane is unstable and may liberate potentially toxic breakdown products.
Mechanism of action of Sevoflurane:
- Inhaled anesthetics can cause alteration of the activity neuronal ion channel activity, particularly fast synaptic neurotransmitter receivers (nicotinic Acetylcholine and GABA receptors).
- The effects of sevoflurane on sympathetic stimulation, including the cardiovascular system, are very limited.
- Sevoflurane does not cause respiratory irritation or circulatory stimulation. The drug may cause myocardial contractility to decrease, and systemic vascular resistance to decrease.
- This may lead to a decrease of blood pressure and sympathetic nerve activity.
- Sevoflurane's blood/gas partition coefficient is low, which is why it is associated with an immediate onset and rapid recovery.
The onset of action: Induction time is within 2 to 3 minutes
Duration:
- Emergence time: Dependant on blood concentration when sevoflurane is discontinued. There is a rapid rate of change of anesthetic concentration in the lung with sevoflurane because its blood gas solubility is low (0.63).
- Sevoflurane's 90% decrement time (time required for an anesthetic concentration in vessel-rich tissues to decrease by 90%) is short when the duration of anesthesia is less than 2 hours but increases dramatically as the duration of administration is increased.
Metabolism: In liver (~5%) via CYP2E1
Excretion: Exhaled gases
International Brand Names of Sevoflurane:
- Sojourn
- Amasevo
- Floves
- Haluran
- Sefether
- Sevo
- Sevocris
- Sevodex
- Sevofran
- Sevofrane
- Sevoran
- Sevorane
- Sevotan
- Sojourn
- Sovener
- Ultane
Sevoflurane Brand Names in Pakistan:
Brands will be updated later.
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