EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Shaban
CLINICAL EFFECETS OF SEVOFLURANE VVERSUS HALOTHANE
IN PEDIATRIC OCULAR SURGERY
By
Mohamed Shaban M. MD.,
Minia Faculty of Medicine
ABSTRACT:
Background:
Many anaethetists prefer inhalational anaesthetics as the sole anaesthetic agent for
induction and maintainance of anaesthesia especially in pediatric surgery.Our study
was designed to evaluate the clinical profile and effects of Sevoflurane and Halothane
on Introcular pressure (IOP) in pediatric patients undergoing elective ophthalmic
surgery.
Methods: This study included 60 children aged 2-10 years old undergoing elective
ocular surgery under general anaesthesia. Patients were randomly classified into two
equal groups according to the selected inhalational anaesthetic agent (Sevoflurane or
Halothane) the following parameters were recorded: induction time intubation
conditions, recovery time, and haemodynamic changes, intraocular pressure was
recorded before induction, after induction, after intubation, before surgery and before
withdrawal of anaesthesia at the end of surgery.
Results: Induction times with sevofl.urane and halothane were 175 (25) seconds and
190 (20) seconds, respectively (P=0.238) the recovery was earlier in sevoflurane
group in comparison to halothane [890.75 (60.11) second and 990.45 (25.19) seconds
respectively], Sevoflorane was characterized by haemodynamic stability in
comparison to Halothane anaesthesia There was no difference between the groups
regarding the intubation conditions In both groups. there was a decrease in the IOP
after induction in halothane and sevoflurane groups [14.11 (1.671) mmhg and 13.75
(2.549) mmhg respectivelly ],with subsequently increase after endotracheal intubation
approaching the base line The rise was more in halothane group [18.80(2.10) mmhg]
than in sevoflorane group [13.64 (1.560) mmhg]. During maintenance of anaesthesia,
IOP decreased in both groups until the end of surgery, with more reduction in lop in
sevoflorane group [12.11(1.881)] than in halothane group [13.55(4.224) mmhg ]
Conclusion : Sevoflurane and Halothane are effective sole anaesthetic agents for
pediatric ocular surgery.Sevoflorane seems to be superior to Halothane regarding the
rapid induction and recovery and more effective reduction of IOP.
KEY WORDS:
Sevoflurane
Halothane
lOP
Pediatric.
thetic are thought to alter TOP in a
number of ways; by an effect on the
central controlling areas in the in]
dbrain by altering intra-and extraocular
muscular tone2. Sevoflurane has gained
popularity in paediatric anaesthesia
since its introduction into the clinical
practice, with its advantages of low
INTRODUCTION:
Intraocular pressure (I.O.P) is
especially important in an emergency
ophthalmic surgery. Factors such as
arterial blood pressure, central venous
pressure, posture and carbon dioxide
concentration can affect the TOP
during anaesthesia1. Inhalational anaes-
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
solubility, rapid induction and recovery
as well as cardiovascular stability3.
Although several authors have described the effects of sevoflurane on the
intraoculer pressure (lop), sufficient
data on the effects of sevoflurane in
children undergoing ophthalmic surgery are lacking3.4.
Shaban
was maintained with halothane 12% end tidal concentration.
Group II: include 30 patient and
received sevoflurane for induction and
maintainance of anaesthesia using
datum sevotic (02740500-England)
vaporizer initial sevoflurane concentration at the start of induction was 3%
in 100% 02 with a maximam cocentration of 8%. During maintenance
sevoflurane concentration was kept
between 2.5-3.4% ends tidal, A
modified A yreas T piece was used for
all patients. The trachea was intubated
by an appropriately sized uncuffed
tube for both groups no supplemental
analgesia and no muscle relaxant were
used for endtracheal intubation and
children were breathing spontanously
Routine monitoring included heat rate,
noninvasive mean arterial blood
pressure (MAP) and arterial oxygen
saturation (SPaO2)
The aim of this study is to
compare the safety and efficacy of
sevoflurane and halothane in paediatric
ocular surgery with study of their
effects on the intraocular pressure.
PATIENTS AND METHODS:
After obtaining our local
Ethics and Research Committee
approval and parental consent, we
included in our study 60 children,
ASA physical status Ior II, aged 2-10
years, weighing 13-30 kg, of both
sexes, scheduled for elective ocular
surgery in the period from September
2004 to march 2006. Children with
expected difficult intubation, significant cardiac, respiratory, renal,
hepatic or neurological disorders were
excluded from the study.
The following parameters
were recorded for all patients, a)
induction time time from the start of
inhalation anaesthesia agent until
insertion of endotracheal tube, b)
intubation conditions were assessed
using special scoring system (table)5.
c) extubation time after discontinaul
of anaesthesia and d) recovery time
(time recored to reach a score of 10
according to aldrete and karodtic
scoring system6 (table2).
All operations were done at
early morning after premedication with
midazolam 0.5 mg/kg orally half an
hour before induction, atropine 0.01
mg/kg is iv. immediately before
induction and instillation of surface
anaesthesia to the conjunctiva with
binoxinate hydrocloride 0.4%.
The IOP was measured using
hand-held, {Schiotz Tonomer} by an
ophthalmologist who was unaware of
the inhalation used. All measurement
were made in the non diseased eve
with the patient supine position, It was
measured at the following intervals
before induction of anaesthesia before
intubation after end tracheal intubations before the start of surgery and
at the end of surgery. Any side effects
and/ or complication were also assessed and recorded.
At the time of induction,
pathients were randomily allocated
into one of the two equal groups:
Group 1: included 30 patients and
received halothane for induction
and maintainance of anaesthesia via
homeda flutec-3 (BBNP02968England vaporizer. The concentration at the start of induction was
1% in 100% 02 with a maximum
concentration of 5% anaesthesia
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Statistical analysis data were
collected before and during surgery
and are expressed as mean (SD).
unpaired students t-test was used to
compare the two groups repeated
measures ANOVA was used to check
differences within each group and
post-hoc analysis was performed if
significant was detected, chi-squared
test was applied to compare the
frequency of sex distribution in the two
groups for all statistical analysis a P
value {0.05was considered significant}
Shaban
respectively (P=0.238) the times for
extubation and to achieve satisfactory
recovery scores were shorter in sevoflurane group than halothane group
(P=0.002) (table 5)
Intraocular pressure was generally more reduced with sevolfurane
than halothane but there were no
statistically significant differences between the two groups. The pattern of
IOP changes was compare-able,
decrease after inhalational induction,
increased after intubation, then slight
decrease before surgery and decrease
again, below the baseline levels, at the
end of surgery. In the halothane
group, there were mild-to-moderate
significant decreases in the IOP in the
following successive readings in comparison to baseline (p<0.05). Except
after intubation where there was no
significant difference from base line
(P <0.05). In the sevoflurane group,
there was a significant reduction in the
IOP in all readings in comparison to
baseline Table 6)
RESULTS:
Demographic and operative data
were comparable in the two study
groups (table 3) heart rate and the mean
arterial blood pressure were signifycantly reduced in group 1 compared to
group 2 (table 4) intubation was successful in all children of the studied
groups at the first attempt without the
need for other interventions. intubating
conditions were comparable in the two
groups (table 5), induction times with
sevoflurane and halothane were 175
(25) seconds and 190 (20) seconds
Table 1: Scoring system for intubation conditions5.
score
larrygoscope
vocal cardes
coughing jaw relaxation
1
Easy
open
Non
complete
None
2
3
4
fair
difficult
Impossible
moving
closing
closed
slight
moderate
sever
slight tone
stiff
rigid
slight
moderate
severe
favourable intubation condition was indicated if any of the 5 variables
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limb
movement
EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Shaban
Table 2: Covert' Score (6)
Score
0
Colour Respiration consciousness
Cyanotic Apnoeic or
2
Activity
Blood
unable to
move
Unresponsive
obstructed
I
Circulation
Pressure ± 50% of pre
-anaesthetic level
Pale or
Shallow
Arousable
dusky
respiration or
dyspnoeic
Pink
Breathes
deeplyand
Awake, alert
and oriented
Blood press ure+20%50% of
Voluntary
pre-anaesthetic level
movemente
of2, limbs
command
Blood pressure ± 20% of
pre-anaesthetic levele
Move all
extremities
to
command
coughs
A score of 10 means complete recovery. Scoring was done every 2 minutes after
discontinuation of anaesthesia for all patients.
Table 3: Demographic and operative data [means (SD), ratio or number (percentage)
of patients].
Age (year)
Wieght (kg)
Height (cm)
Gende (Male/finale)
Duration of surgery (min)
Type of surgery Cataract
Lid operation
Squint
Others
Halothane
(n=30)
5.6 (2.2)
25.5 (8.1)
110.2 (18.1)
17/13
66.5 (25.8)
Sevoflurane
(n=30)
5.4 (1.6)
24.8 (7.0)
112.7(15.5)
18/12
64.3 (26.6)
918(6%)
(30%)
3 (10%)
0 (0%)
9 (30%)
15(50%)
3 (10%)
3 (10%)
Table 4: Changes in the vital signs In both groups [means (SD )
------------------------------------------------------------------------------------------------------Heart rate ( beats / min))
MAP (mmhg
artial o2 saturation (%)
------------------------------------------------------------------------------------------------------------------------------------------
halo
sevo
sevo
halo
sevo
Halo
-----------------------------------------------------------------------------------------------------------------------------------------before induction
97.5(5.7)
103.6(9.4)
64.0(6.0)
69.8 (74.0)*
97.9(1.1)
98.3(1.2)
after induction
101.1(9.1)
108.6(8.6)*
54.0(4.6)
61.2(9.0)*
98.8(0.8)
99.3(0.6)
after intubatio
110.3(11.0)
117.6(7.2)*
58.0(3.8)
66.2(9.2)*
98.2(1.7)
99.1(1.0)
before surgery
117(9.7)
119.5(8.3)*
58.1(3.8)
65.8(9.2)*
99.1(0.7)
99.1(0.7)
at end of surgery
88.2(8.2)
109(5.9)*
55.1(4.9)
64.2(8.6)*
98.8(0.8)
99.2(0.6)
 Statistically significant difference (P<0.05) between groups .
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Shaban
Table 5: Intubating conditions. Induction time and time to reach score 10 (seconds)
values are mean (SD).
intubation condition accepted
intubation condition unaccepted
induction time
Halothane (n=30)
27(90%)
3(10%)
190.0(20)
Sevoflurane (n=30)
27(90%)
3(10%)
175(25)
650.5(90.5)
extubation time
990.45(25.19)
time to reach score 10
Statistically significant differences (P<0. 05) between groups
225.2(25.2)*
890.7(60.11)*
Table 6: Changes in the IOP (mmhg) {mean (SD)
Time
before induction
after induction
after intubation
before surgery
at end of surgery
halothane (n=30)
17.75(2.9)
14.11(1.671)
18.80(2.10)**
14.2(1.5)*
13.4(2.9)*
Sevoflurane (n=30)
17.78(3.9)
(n=3012,75(2:549)*
)
14.7(5.7)*
13.64(2.5)*
12.8(2.1)*
*statistically significant (P<0.05) compared to basline value in the same group.
**statistically significant (P<0.05) compared to the other group.
There was no difference in the
intubating conditions between the two
groups in this study; an observation
that seems to be similar to other studies
in which the incidence of complications during induction with sevoflurane and halothane was similar9
Jackson et al.,10 suggested that sevoflurane could be a reasonable alternative to succinylcholine for intubation
in elective pediatric surgery and the
time required for satisfactory intubating conditions without neuromuscular blocking agents has been
shown to be lower for sevoflurane than
for halothane. The time required for
extubation and to attain full recovery
criteria was shorter with sevoflurane in
comparison to halothane group and this
was in accordance with other studies
and are attributed to the known differences in blood-gas solubility of the two
agents. Sevoflurane, having the lowest
blood-gas solubility, is more rapidly
DISCUSSION:
In present study, we compared
the effects of halothane versus sevoflurane anaesthesia in pediatric ocular
surgery. We found that the induction
time tended to be shorter in sevoflurane group than halothane group but
this difference was statistically insignificant. These results are in agreement
with Arrifin et al.,7 who studied 375
children assigned randomly to receive
either sevoflurane or halothane. They
compared the induction and recovery
criteria in both groups and found that
induction and recovery were rapid in
patients who received sevoflurane.
Sevoflurane lacks pungency even at
high inspired concentrations. This
allows as much as 8% to be delivered
without significant breath-holding,
coughing or laryngospasm. Clinical
experience shows that this concentration is well tolerated and allows
more rapid induction than halothane8.
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
washed out from the body and has
fastest recovery due to rapid fall of
brain
partial
tension
of
the
11
anaesthetic .
Shaban
on the IOP were nearly similar in the
pattern of occurrence, but with more
reduction of the IOP, to halothane in
pediatric ophthalmic surgery. This
similar effect on IOP between halothane and Sevoflurane may be explained by the similarity in cardiovascular effects during induction3.
There was a drop in the IOP in both
groups below the baseline after
inhalation anesthetics. The possible
mechanisms include relaxation of
intraocular and extraocular muscles
and facilitation of the flow aqueous
humour. After tracheal intubation, the
IOP rose approaching the baseline
Value in the two groups; this may be
due to catecholamine response to
laryngoscopy. And this is similar to the
results reported by Ate et al.,3 and
Kawana et al.,16 in paediatric patients
without using muscle relaxants. The
combination of sevoflurane with i.v.
remifentanil were not associated with
an increase in IOP or homodynamic
stress response during tracheal intubation or Laryngeal mask airway from
the baseline levels in pediatric patients
undergoing ophthalmic surgery17.
Also, the use of laryngeal mask airway
instead of tracheal intubation or the
addition of muscle relaxant to Sevoflurane anaesthesia can attenuate this
increase of the IOP associated with
tracheal incubation response3.
Viitanen et al.,9,12 showed that,
in children 1-3 years of age,
sevoflurane provided more rapid and
earlier recovery but not discharge after
an aesthesia of < 30 minutes duration.
Apart from more vomiting with
halothane and more discomfort during
the first 10 minutes after awakening
with sevoflurane the quality of
recovery was similar with the two
anaesthetics.
Another more detailed study on
the recovery conditions showed that
the time to tracheal extubation, the
time taken to open eyes in response to
verbal command, the time to demonstrate purposeful movement such as
Squeezing the hands and the time to
full recovery using Aldrete's recovery
Score were significantly less in children receiving sevoflurane than those
receiving halothane 13.
The IOP may be affected in a
variety of ways by drugs given in the
peri operative period by altering the
physiological determinants of IOP.
They may act directly to induce
changes in the intraocular blood
volume or locally by altering tone of
the extraocular and intraocular
muscles2. Most inhalational anesthetics
produce a reduction of the IOP in a
dose-dependent manner, and few
advantages have been attributed to one
over another. Halothane has been
shown to decrease IOP both when used
with controlled or spontaneous
breathing14. When halothane was
replaced by Sevoflurane/nitrous Oxide
or
Sevoflurane/remi-fentanil
the
magnitude of reduction of the IOP was
comparable15. In the present study, we
found that the effects of Sevoflurane
Acknowledgement:
We would like to think Dr. Ahmed
M. Sabry lecturer of Ophthalmology
for his help in IOP monitoring.
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Shepherd WF; comparison of enflurane
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3- Ates M, Cemile O, Selimin O,
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4- Black M,Sur L,Hemington R,
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5- Grants S, Nobles S, woods A
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9- Lerman J, Davis PJ,
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Anesthesiology 1996; 84:1332-1338.
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13- Sarner JB, Levine M, Davis
PJ, Lerman J, et al.,: Clinical characterstics of sevoflurane in children:
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14- Vanden Berg AA, Honjol
NM, Prabhu NV, et al.,: Spontanous
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15- Artru AA, Momota Y:
Trabecular out flow facility and
formation rate of aqueous humor
during anaesthesia with sevoflurane nitrous
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16- Kawana S, Wachi J,
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‫‪EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007‬‬
‫التاثيرات األكلينيكية للسيفوفلورين مقابل الهالوثان في جراحة العيون في األطفال‬
‫محمد شعبان‬
‫قسم التخدير – كلية طب المنيا‬
‫أجريتتت الدراستتة فتتي مستشتتفي المنيتتا الجتتامعي فتتي الفتتتر متتن ستتبتمبر ‪ 2004‬إلتتي متتار ‪200 6‬‬
‫لمقارنة عقار السيفوفوفلورين مقابل الهلوثان علي ‪ 60‬طفال لكل عقار يتراوح أعمارهم من ‪– 2‬‬
‫‪ 10‬سنوات وتم قيا التغيرات في ضغط العين والوقتت التال م لكتل عقتار للواتول التي حالتة‬
‫التختتدير العتتام وكتتالر تتتوافر الحتتا ت المال متتة لوض ت قستتطر القاتتبة الهوا يتتة وكتتالر قيتتا‬
‫التغيرات في دينمية الدم والنبض وكالر الوقت الال م لألفاقة بعد إيقاف استنشاق العقار‬
‫وأظهرت النتا ج أن الوقتت التال م للتختدير العتام لألطفتال بعقتار الستيفوفلورين أقتل منتي فتي حالتة‬
‫الهالوثان وكالر ثبتات معتد ت دينميتة التدم والنتبض فتي حالتة الستيفوفلورين اقتل منتي فتي حالتي‬
‫الهالوثتتان وكتتالر فتتان العقتتارين متشتتابهان و يوجتتد بينهمتتا فتترق فتتي تتتوافر الحتتا ت المتال متتة‬
‫إلمكانية وض أنبوبة القابة الهوا ية كما أظهترت النتتا ج نقت فتي معتد ت ضتغط العتين فتي‬
‫كلتا العقارين وأن النق في ضغط العين يكون اكبر في حالة السيفوفلورين طيلة العملية أما في‬
‫الفتر بعد وض األنبوبة الحنجرية فاني يوجد ياد فتي ضتغط العتين فتي كتل متن العقتارين وان‬
‫هاه ال ياد تكون اكبر في حالة الهالوثان‪.‬‬
‫ونستنتج من الدراسة ‪ -:‬إن كل من السيفوفلورين والهالوثتان يمكتن استتخدامهما فتي التختدير العتام‬
‫لعمليات العيتون لألطفتال ويفضتل عقتار الستيفوفلورين بتنتي يتميت بقاتر فتتر التختدير الال متة‬
‫للواول الي التخدير العام وكالر قار فتر األفاقة ويتمي بنق في ضغط العين الداخلي كمتا‬
‫يتمي بثبات معد ت دينمية الدم العام والنبض ‪.‬‬
‫‪305‬‬