Sevoflurane Vs Desflurane Evaluation of Cognitive Functions in Elderly Patients Undergoing Surgeries

Dissertation on
“TO COMPARE THE COGNITIVE FUNCTION AND RECOVERY

CHARACTERISTICS AFTER DESFLURANE VERSUS SEVOFLURANE
ANAESTHESIA IN ELDERLY PEOPLE POSTED FOR VARIOUS
SURGICAL PROCEDURES UNDER GENERAL ANAESTHESIA”
- A PROSPECTIVE, RANDOMISED AND DOUBLE
BLINDED CLINICAL TRAIL.
A Dissertation Submitted to the
Dr. N.T.R UNIVERSITY OF HEALTH SCIENCES,

VIJAYAWADA
In Partial fulfillment of
The regulations for the award of
M.D. (ANAESTHESIOLOGY)
Degree Examination to be held in APRIL 2019
By
Dr. ARASAVALLI SIVANWESH, M.B.B.S.
Under the direction and guidance of
Dr. T. PREM SAGAR, M.D.

Professor
Department of Anesthesiology
Rangaraya Medical College,
Government GeneralHospital,
Kakinada
RANGARAYA MEDICAL COLLEGE
KAKINADA
CERTIFICATE
This is to certify that this dissertation on “TO COMPARE THE
COGNITIVE FUNTION AND RECOVERY CHARACTERISTICS AFTER
DESFLURANE VERSUS SEVOFLURANE ANAESTHESIA IN ELDERLY
PEOPLE POSTED FOR VARIOUS SURGICAL PROCEDURES UNDER
GENERAL ANAESTHESIA - A Prospective Randomized double blinded
clinical trial” has been carried out by Dr.ARASAVALLI SIVANWESH,
Registration No. M160403026 under my direction, guidance and supervision
in partial fulfillment of regulations laid down by D r .N.T.R.UNIVERSITY OF
HEALTH SCIENCES, VIJAYAWADA for M.D.(ANAESTHESIOLOGY)
Degree Examinations to be held in April 2019.
Kakinada Dr.T. PREM SAGAR, M.D

Professor
Date: Department ofAnaesthesiology
Rangaraya Medical College
Government General Hospital
Kakinada
Dr. B.SOWBHAGYA LAKSHMI, M.D.

Professor& Head
Department of Anaesthesiology
Government General Hospital
Kakinada
PRINCIPAL
Rangaraya Medical College,
Kakinada.
DECLARATION BY THE CANDIDATE
I Dr.ARASAVALLI SIVANWESH here by declare that this dissertation thesis entitled
ANAESTHESIA IN ELDERLY PEOPLE POSTED FOR VARIOUS SURGICAL
PROCEDURES UNDER GENERAL ANAESTHESIA – A Prospective,
Randomised and double blinded clinical trail’’ is a bonafide and genuine research
work carried out by me under the expert guidance and supervision of Dr. T.PREM
SAGAR, M.D, Professor, Department Of Anaesthesiology, Rangaraya Medical
college, Kakinada,in partial fulfillment for the award of Doctor of Medicine (MD) in
Anaesthesiology by Dr. N.T.R University of Health Sciences , Vijayawada and the
examination to be held in 2019.
This study was conducted at Government General Hospital, Kakinada. I
have not submitted this dissertation previously to any university for the award of any
degree or diploma.
Place: Kakinada
Date:
Dr. ARASAVALLI SIVANWESH
Postgraduate student
Department of Anaesthesiology,

ACKNOWLEDGEMENTS
It is with an overwhelming sense of gratitude and respect that I

Acknowledge my indebtedness to my teacher and guide Dr.T.PREM SAGAR,
M.D, Professor, Department of Anaesthesiology, Rangaraya medical college,
Government General Hospital, Kakinada, for the scholarly pain taking and
expert guidance at each stage in completing this dissertation.
I owe my heartfelt gratitude and utmost respect to Dr. B. SOWBHAGYA

LAKSHMI, M.D., Professor and Head of the Department of Anaesthesiology.
Rangaraya Medical College & Chief Anaesthesiologist, Government General
Hospital, Kakinada, for her motivation , keen interest, valuable suggestions and
constant supervision during the conduct of the study.
I am very grateful to Dr. K.VIJAYENDRA KUMAR BABU, M.D.,

Professor, Department of Aneasthesiology, Rangaraya Medical College and
Chief Anaesthesiologist , Government General Hospital, Kakinada for his
guidance in carrying out this work.
I sincerely thank Dr.A.VISHNU VARDHAN, M.D., Professor,

Department of Anaesthesiology, Rangaraya Medical College, Kakinada, his
valuable advice at every step of this study.
I am extremely thankful to Dr.P. KRISHNA PRASAD, M.D., Associate

Professor, Department of Anaesthesiology, Rangaraya Medical College,
Kakinada, for his valuable inputs at every step of this study.
I am greatly indebted to my Co-guide Dr. B. VISHNU MAHESH BABU,

M.D., Associate Professor, Department of Anaesthesiology, Rangaraya
Medical College, Kakinada, for his ideas, valuable inputs and immense support
throughout the period of this study.
I am thankful to Dr. PRASANNA KUMAR, M.D., Associate Professor,

Department of Anaesthesiology, Rangaraya Medical College, Kakinada for his
advice throughout the study.
I am thankful to Dr. K. VINDHYA, M.D., Associate professor, Department of
Anaesthesiology, Rangaraya Medical College, Kakinada, for her advice and
encouragement during thestudy.
I express my thanks to all my Assistant Professors, Dr. Y. ATCHYUTHA

RAMAIAH M.D., Dr. S. PARVEEN, MD.,DA.,Dr. SNEHA LATHA,MD. Dr.RAMARAO,
MD.,DA. Dr.ARUNA KUMARI, MD. Dr. LAXMANA RAO,MD., Dr.S.ANAL
KUMAR,MD., Dr.PRAVEENA,MD., Dr.LAKSHMI NARAYANA, DA.Dr, SATHISH,
DA., Dr.HARINATH DA., ,
for helping me in completing this study.
I am very thankful to all my fellow postgraduates, seniors and juniors for their
help in this study.
I wish to thank all the members of the faculty of Department of General surgery
and S.P.M. for permitting me to conduct the study on their patients who are posted for
elective surgeries.
I am thankful to Dr. MAHA LAKSHMI, M.S., Principal, Rangaraya Medical

College, Kakinada and Dr. M.RAGHAVENDRA RAO MD,DTCD,FCCP,
Superintendent, Government General Hospital, Kakinada for having permitted me to
use the facilities in the hospital and records for the conduct of the study.
Last but not the least, I thank all the patients who subjected themselves to this
study, as without their co-operation this dissertation would not have beencompleted.
Dr.ARASAVALLI SIVANWESH
Postgraduate student
Department of Anaesthesiology,
LIST OF ABBREVIATIONS USED
Sevo- sevoflurane
Des- desflurane
Mmse- mini mental status examination
POCD- post operative cognitive dysfunction
CFQ- Cognitive failure questonaire
MAC- minimum alveolar concentration
ASA- American society of anesthesiologists
nAchR- n acetyl choline receptor \
NP tests- Neuropsycological tests
ECG- electrocardiogram
NIBP- Non invasive blood pressure
Intraop: intra operative
Post op: post operative
orif Open reduction and internal fixation
Pcnl Percutaneous nephro lithotomy
TABLE OF CONTENTS
1. INTRODUCTION ........................................................................................................ 1
2. AIM OF THE STUDY ................................................................................................. 3
3. UPTAKE AND DISTRIBUTION OF INHALATIONAL ANESTHETICS........ 4
4. THEORIES OF ANESTHETIC ACTION ................................................................. 8
5. PHARMACOLOG:DESFLURANE .......................................................................... 10
SEVOFLURANE
6. TEC 6 VAPORIZER ................................................................................................... 12
7. INHALED ANESTHETICS AND COGNITIVE PERFORMANCE .................... 17
8. REVIEW OF LITERATURE .................................................................................... 19
:HISTORY : INCIDENCE AND. RISK FACTORS FOR POCD
:STUDIES COMPARING SEVOFLURANE AND DESFLURANE
9. MATERIALS AND METHODS ................................................................................ 38
10. STATISTICAL ANALYSIS ...................................................................................... 42
11. OBSERVATION AND RESULTS......................................................................... 43
12. DISCUSSION.............................................................................................................. 59
13. CONCLUSION ........................................................................................................... 65
14. SUMMARY ................................................................................................................. 66
15. BIBLIOGRAPHY ........................................................................................................67
16. ANNEXURES ............................................................................................................. 75

LIST OF TABLES
Table 1: Partition coefficients of volatile anesthetics ...................................................... 6

Table 2: Tissue groups based on perfusion and solubilities ............................................. 7
Table 3: Physical constants of desflurane .......................................................................11
Table 4: Predisposing factors for postoperative delirium .............................................. 24
Table 5: Mini mental status examination(MMSE) ......................................................... 30
Table 6: Interpretation of MMSE scores ........................................................................ 31
Table 7: Distribution of mean age in years among treatment groups… ........................ 43
Table 8: Distribution of gender among the treatment groups… ................................... 44
Table 9: Comparision of ASA grading between the treatment groups… ......................45
Table 10: Comparision of mean BMI between the treatment groups… .........................46
Table 11: Comparision of the types of surgeries between the treatment groups. ........... 47
Table 12: Comparision of mean duration of anesthesia and surgery between the treatment
Groups .............................................................................................................. 48
Table 13: Comparision of mean propofol and fentanyl requirements in the treatment
groups. ............................................................................................................. 49
Table 14:Comparision of recovery indices between the treatment groups ...................... 50
Table15: Comparision of side effect profile the treatment groups… .............................. 51
Table 16:Comparision of post operative analgesic requirements between the treatment
groups… ............................................................................................................. 52
Table 17: Trend of MMSE scores over time .................................................................... 53
Table 18: Comparision of mean mmse scores between the treatment groups… ..............55
Table 19: Comparision of percentage of patients having POCD ...................................... 57
LIST OF GRAPHS/CHARTS
graph 1: Distribution of mean age in years among treatment groups…....................... 43

graph 2: Distribution of gender among the treatment groups… ................................. 44
graph 3: Comparision of ASA grading between the treatment groups… .................... 45
graph 4: Comparision of mean BMI between the treatment groups… ........................ 46
graph 5: Comparision of the types of surgeries between the treatment
groups. ............................................................................................................. 47
graph 6: Comparision of mean duration of anesthesia and surgery between the treatment
Groups .............................................................................................................. 48
graph 7:Comparision of mean propofol and fentanyl requirements in the treatment
groups. .............................................................................................................. 49
graph8: Comparision of recovery indices between the treatment groups… ................50
graph 9: Comparision of side effect profile the treatment groups… ............................ 51
graph 10: Comparision of post operative analgesic requirements between the treatment
groups… .......................................................................................................... 52
graph11: Trend of MMSE scores over time .................................................................. 56
graph12: Comparision of percentage of patients having POCD the treatment groups. 57
graph 13: Repressentation of total no of patients having POCD ................................... 58
INTRODUCTION
Cognitive impairment (e.g. confusion, delirium) is a significant problem in elderly
patients during the early postoperative period 1, 2,3,4.
The postoperative delirium in the elderly can result in increased morbidity, delayed
functional recovery, and a prolonged hospital stay and the resulting immobilization is
associated with further complications like decubitus ulcers, pneumonia or thrombosis.
There is personal loss to patients who might not return to their baseline level of cognitive
function, despite a successful surgical procedure.5 Alarmingly, patients experiencing POCD
are at a cumulative risk of death in the first year after surgeries.
The incidence of cognitive impairment has been reported to be between 1% and 60%,
depending on the type of operation5.
Cognitive impairment after cardiac operations has been studied effectively but cognitive
decline after noncardiac operations has not so well studied.
More noncardiac operations are conducted each year, which could lead to a greater
number of patients having a cognitive impairment.
The use of volatile anesthetics that are quickly get rid of with minimal metabolic breakdown
may reduce postoperative delirium and cognitive impairment in elderly surgical patients by
facilitating a faster recovery from general anesthesia.
1
Sevoflurane and desflurane have pharmacokinetic properties that favours the rapid
emergence from anaesthesia.
This is as a result of differences in blood: gas (0.45 vs 0.65) and fat: blood partition (27
vs 48) coefficients of desflurane versus sevoflurane, respectively6.
The lower partition coefficients of desflurane favour its more rapid elimination from the
body and also provide for shorter emergence times.
The use of shorter-acting anesthetic and analgesic agents may contribute to faster
emergence and less postoperative cognitive impairment and confusion in elderly patients.
2
AIMS AND OBJECTIVES
1. To compare the speed of recovery in elderly patients undergoing
general anesthesia with sevoflurane or desflurane.
2. To determine the incidence and duration of cognitive impairment in
elderly patients undergoing general anesthesia with a sevoflurane or
desflurane-based technique.
3
INHALED ANESTHETICS7
The mechanism of action of inhalation anesthetic agents remains unknown, the ultimate
effect depends on attainment of a therapeutic tissue level in the CNS.
UPTAKE AND DISTRIBUTION
FACTORS AFFECTING INSPIRATORY CONCENTRATION 7,8 (FI)
The fresh gas exit the anesthesia machine mixes with gases in the breathing circuit before
being inspired by the patient. Therefore, the patient is not necessarily getting the
concentration that is delivered by various vaporizers.
The composition of the inspired gas mixture depends mainly on the a) fresh gas flow rate,
b) the volume of the breathing system, and c) any absorption by the machine or breathing
circuit7. The grater the fresh gas flow rate, the lesser the volume of breathing system , and
the minimal circuit absorption causes inspired gas concentration will be almost nearer to
the fresh gas concentration.
FACTORS THAT ALTERS ALVEOLAR CONCENTRATION ARE :(FA)
Uptake
If there were no uptake of anesthetic drugs by the body, the alveolar gas concentration
(FA) would quickly reach the inspired fresh gas concentration (FI).
Because anesthetic drugs are taken up by the pulmonary circulation during induction,
alveolar concentrations lag behind inspired concentrations8 (FA/FI less than 1.0). The
greater the
4
uptake of agents, the rate of rise of the alveolar concentration will be lo
wer and lesser the FA/ FI .
The alveolar partial pressure is significant because it determines the partial pressure of
anesthetic in the blood and, ultimately, in the brain. Likewise, the partial pressure of the
anesthetic in the brain is directly proportional to its brain tissue concentration, which
determines clinical effect.
Therefore, the bigger the uptake of anesthetic agents, the greater the difference between
inspired gas and alveolar gas concentrations, and the slower the rate of induction.
Three factors affect anesthetic uptake7:
a) Solubility in the blood,
b) Alveolar blood flow,
c) The difference of partial pressure between the alveolar gas and venous blood
The relative solubilities of an anesthetic agents in air, blood, and tissues are stated as
Partition coefficients. Each partition coefficient is the ratio of the concentrations of the
anesthetic gas in each of two phases on equilibrium. Equilibrium is defined as equal partial
pressures in the two phases.7
5
TABLE 1:Partition Coefficients of Volatile Anesthetics at 37°c.7
Agent Blood/Gas Brain/Blood Muscle/Blood Fat/Blood
Nitrous oxide 0.47 1.1 1.2 2.3
Halothane 2.4 2.9 3.5 60
Isoflurane 1.4 2.6 4.0 45
Desflurane 0.42 1.3 2.0 27
Sevoflurane 0.65 1.7 3.1 48
The second factor that affects uptake stays alveolar blood flow, which in the absence of
pulmonary shunting is essentially equal to cardiac output.
As CO increases, anesthetic uptake increases, the increase in alveolar partial pressure
slows, and induction is delayed. Hence, low-output states predispose patients to over
dosage with soluble agents, as the rate of rise in alveolar concentrations will be markedly
increased.
The final factor affecting uptake of anesthetic to the pulmonary circulation is the partial
pressure difference between alveolar gas and venous blood. This gradient depends on
tissue uptake. The transfer of anesthetic agentsfrom blood to tissues is determined by three
factors analogous to systemic uptake7: a) tissue solubility of the agent, b) tissue blood flow,
c) the difference of partial pressure between arterial blood and the tissue.
6
Tissues are divided into 4 groups based on their solubility and blood flow 7
TABLE 2:Tissue Groups Based on Perfusio
n and Solubilities.
Characteristic Vessel Rich Muscle Fat Vessel Poor
Percentage(%) of body weight 10 50 20 20
Percentage(%) of cardiac 75 19 6 0
output(CO)
Perfusion (mL/min/100 gm) 75 3 3 0
Relative solubility 1 1 20 0
Anesthetic agent uptake produces a characteristic curve that relates
the rise in alveolar concentration to time.
7
8
FACTORS AFFECTING ARTERIAL CONCENTRATION
Ventilation/Perfusion(V/Q) Mismatch
Normally alveolar and arterial anaesthetic partial pressures are assumed to be equal, but
in fact the arterial partial pressure is constantly less than end-expiratory gas would predict.
Reasons for this are because of a venous admixture, alveolar dead space, and nonuniform
alveolar gas distribution8
FACTORS AFFECTING ELIMINATION:
Recovery from anesthesia depends on dropping the concentration of anesthetic
in brain tissue.
Anesthetics can be removed by biotransformation, transcutaneous loss, or exhalation.
Biotransformation usually accounts for a slight increase in the rate of decline of alveolar
partial pressure.
The most important route for excretion of inhalation anesthetics is the alveolus 8.
Several factors that speed induction also speed recovery: elimination of rebreathing, more
fresh gas flows, minimal breathing circuit volume, low absorption by the anesthetic circuit,
decresed solubility,high cerebral blood flow (CBF), and increased ventilation.
The rate of recovery is frequently faster than induction because tissues that have not
reached equilibrium will continue to take up anesthetic agent until the alveolar partial
pressure falls below the tissue partial pressure, fat will continue to take up anesthetic and
hasten recovery until the partial pressure exceeds the alveolar partial pressure.7
This redistribution is not as available after prolonged anesthesia thus, the speed of
recovery also depends on the length of time the anesthetic agent has been administered.
9
THEORIES OF ANAESTHETIC ACTION :
General anaesthesia is an altered physiological state characterized by reversible loss of
consciousness, analgesia , amnesia, and muscle relaxation
There is no single site of action that is shared by all inhalational agents. Specific brain
areas affected by various anesthetic agents include the reticular activating system(RAS),
the cerebral cortex, the olfactory cortex, and the hippocampus. 9
Anesthetics have also been shown to reduce excitatory transmission in the spinal cord,
particularly at the level of the dorsal horn interneurons of spinal cord that are involved in
pain transmission.
Unconsciousness and amnesia are probably facilitated by cortical anaesthetic action,
whereas the suppression of withdrawal from painful stimuli may be related to subcortical
structures such as the spinal cord or brain stem.
The unitary hypothesis proposes that all inhalational agents share a common mechanism
of action at molecular level. Anaesthetic potency of inhalation agents correlates directly
with their lipid solubility (Meyer–Overton rule)9 . The implication is that anaesthesia results
from molecules dissolved at specific lipophilic sites.
Neuronal membranes contains a multitude of hydrophobic sites in their phospholipid
bilayer. Anesthetic binding to these sites could enlarge the bilayer beyond a critical amount,
altering membrane function (critical volume hypothesis). Anesthetic binding might also
significantly modify membrane structure.
10
Two theories suggest disturbances in membrane form 1) the fluidization theory of
anesthesia and the 2) lateral phase separation theory. Another theory proposes decreases
in membrane conductance. General anaesthetic action could be due to alterations in one
of several cellular systems including ligand-gated ion channels, second messenger
functions, or neurotransmitter receptors.9
PHARMACOLOGY OF
DESFLURANE:
Desflurane is a fluorinated methyl ethyl ether that alter from isoflurane by the just one atom:
a fluorine atom is replaced for a chlorine atom on the ethyl component of isoflurane.
The process of completely fluorinating the ether molecule has several effects. It declines
blood and tissue solubility (the blood: gas solubility of desflurane equals that of nitrous
oxide), and it results in a loss of potency (the MAC of desflurane is five times higher than
isoflurane)10
The complete fluorination of the methyl ether molecule results in a high vapor pressure
(owing to decreased intermolecular attraction). Thus, a new vaporizer technology has been
developed to deliver a regulated concentration of desflurane as a gas.
A heated, pressurized vaporizer requiring electrical circuit is required. The benefit of
desflurane is the near-absent metabolism to serum trifluoroacetate.
Desflurane is the most common pungent of the volatile anaesthetics and cannot be
delivered via the face mask as it results in coughing, salivation, breath holding, and
laryngospasm.
In extremely dry CO2 absorbers, desflurane degraded into carbon monoxide(CO).
11
Desflurane has the lower blood: gas solubility of the potent volatile anaesthetics; moreover,
its fat solubility is roughly half of that of the other volatile anesthetics. Thus, desflurane offers
a advantage in long surgical procedures by virtue of decreased tissue saturation. 10
Desflurane has been associated with higher heart rate, blood pressure, and, in select cases,
myocardial ischaemia when used in higher concentrations or rapidly increasing the inspired
concentration.
This agent is generally used toward the end of anesthesia to facilitate rapid emergence.
TABLE 3: Some physical constants are:
Molecular weight 168.04
Specific gravity (at 1.465
20°C/4°C)
Vapor pressure in mm Hg 669 mm Hg @ 20°C
731 mm Hg @ 22°C
757 mm Hg @ 22.8°C (boiling
point;1atm)
764 mm Hg @ 23°C
798 mm Hg @ 24°C
869 mm Hg @ 26°C
12
Partition coefficients at 37°C:
Blood/Gas 0.424
Olive Oil/Gas 18.7
Brain/Gas 0.54
13
TEC 6 VAPORIZER:
The Tec 6 vaporizer is a electrically heated, pressurized device specifically designed to
deliver desflurane. The vapor pressure of desflurane is three to four times( 669mm hg) that
of other contemporary inhaled anesthetics, and it boils at 22.8°C, 9 which is near room
temperature.
CONSTRUCTION: The concentration dial at the top is calibrated from 1% to
18% in gradations of 1% up to 10% and 2% between 10% an d 18%. A
dial release at the back of the dial must be depressed to turn the dial from
the standby position or to dial concentrations over 12%. This release
cannot be depressed unless the operational light -emitting diode (LED) is illuminated. 11The
filler port is at the front on the left. It is designed so
that only a desflurane -specific bottle can be inserted into filler port. The power
cord attachment and battery case are on the bottom. The battery provides power
for the alarms and liquid crystal level indicator during mains power failures. On
the front lower right of the vaporizer is the display panel,
which has visual indicators for vaporizer functions .11 The amber warm-up
LED indicates an initial warm -up period after the vaporizer is first connected to the
mains power. Once warm -up is complete, the green operational LED stays
illuminated indicating the vaporizer has reached its workig temperature
and the concentration dial can be turned ON. A short tone sounds at the
transition from warmup to operational.
The red no output LED flashes and an auditory alarm of repetitive tones sounds
if the vaporizer is not able to deliver vapor. This can be caused by
14
an agent level less than 20 mL, tilting the vaporizer more than 10 degrees, power
failure, or an internal malfunction . The liquid level indicator has a liquid crystal
display (LCD) that indicates the amount of liquid in the vaporizer between 50 and
425 ml. The LCDs are visible whenever the vaporizer is powered. There are 20
bars. A single bar corresponds to a volume of nearly 20 mL. An arrow on the
side indicates the 250 mL refill mark. Desflurane is heated to 39°C (102° F) 11 ,
which is well above its boiling point, by two heaters in the base. An external
heat source is needed, because the potency of desflurane requires that large
amounts be vaporized . The vaporizer is calibrated for flows from 0.2 to 10
L/minute
Operating Principles of the Tec 6 :
Tec 6 is more accurately described as a dual-gas blender than as a vaporizer9.
The vaporizer has two different gas circuits arranged in parallel A) The fresh gas circuit,
and B) the vapor circuit.
Fresh gas from the flow meters enters to the fresh gas inlet, passes along a fixed restrictor
(R1), and exits through the vaporizer gas outlet. The vapor circuit originate at the desflurane
sump, which is electrically heated and thermostatically controlled to 39°C, a temperature
above desflurane's boiling point.
The heated sump assembly serves as an reservoir of desflurane vapor.
At 39°C, the vapor pressure in the sump is approximately 1300 mm Hg absolute, or
approximately 2 atm absolute. Just downstream after the sump is the shut-off valve.
15
After the vaporizer heaten up, the shut-off valve entirely inaugurates when the concentration
control valve is used to the "on" position. A pressure-regulating valve positioned
downstream from the shut-off valve downregulates the pressure to approximately 1.1 atm
absolute (74 mm Hg gauge) at a fresh gas flow rate of 10 L/min. The operator controls the
output of desflurane by adjusting the concentration control valve (R2), which is a variable
restrictor. The vapor flow through R2 connects the fresh gas flow through R1 at a point
downstream from the restrictors9.
When a continuous fresh gas flow rate encounters the fixed restrictor R1, a specific
backpressure equivalent to the fresh gas flow rate drives against the diaphragm of the
control differential pressure transducer. The differential pressure transducer carries the
pressure difference between the fresh gas circuit and the vapor circuit to the control
electronics system.
The control electronics system regulates these pressure-regulating valve so that the
pressure in the vapor circuit matches the pressure in the fresh gas circuit. This equalized
pressure supplying R1 and R2 is the working pressure, and the working pressure is constant
at a fixed fresh gas flow rate.9 If the operator increases the fresh gas flow rate, more
backpressure is exerted on the diaphragm of the control pressure transducer, and the
working pressure of the vaporizer progress .
16
Tec 6 vaporizer
17
Sevoflurane:
Sevoflurane is a sweet-smelling, totally fluorinated methyl isopropyl ether10 .
Its vapor pressure is most similar to that of enflurane and it can be practiced in a standard
vaporizer.
The blood: gas solubility of sevoflurane is second only to desflurane in terms of potent
volatile anaesthetics. Sevoflurane is nearly half as potent as isoflurane, and some of the
preservation of potency, despite fluorination.
Sevoflurane has minimal odor, no pungency, and is a potent bronchodilator.
These attributes make sevoflurane better for administration via the face mask on induction
of anesthesia in both children and adults. Sevoflurane is half as potent coronary vasodilator
as isoflurane, but is 10 to 20 times more vulnerable to metabolism than isoflurane. Like that
of enflurane and methoxyflurane, the metabolism of sevoflurane ends in inorganic
fluoride; the increase in plasma fluoride after sevoflurane administration has not been
associated with renal concentrating defects, as is the case with methoxyflurane.
Unlike other potent volatile anesthetics, sevoflurane is not metabolized to trifluoroacetate;
rather, it is metabolized to an acyl halide (hexafluoroisopropanol)10.
Sevoflurane can form carbon monoxide during exposure to dry C2arbondioxide absorbents
and an exothermic reaction in dry absorbent has give rise to canister fires. Sevoflurane
degraded in the presence of the carbon dioxide absorber to form a vinyl halide called
compound A.
18
INHALED ANESTHETIC AND COGNITIVE PERFORMANCES
The target organ for the anesthetic drugs is the brain. For many years, it has been
presumed that their effects do not outlive their pharmacological action, that the target
organ is returned to its earlier state once the agent is excreted.
There is growing evidence that that long term or even permanent neuronal and
neurological change can follow administration of anesthetic agents. The brain appears
to be particularly defenseless at the beginning and end of its life.12
The initial manifestation of neuronal damage in the brain is a waning in the superior
cortical functions of storage , recall of memory and cognitive functiong.
Anesthetics given during surgery produce fluctuations in the patient’s behavioral state by
modifying brain activity via at least two mechanisms: dose-dependent global and regionally
specific, suppression of neuronal activity and disruption of functional interactivity within
distributed neural networks .
Neurotransmitter-gated ion channels, particularly receptors for γ-aminobutyric acid (GABA),
glutamate and N-methyl D-aspartate (NMDA) channels are modulated by most
anaesthetics, at both synaptic and extrasynaptic sites, and additional ion channels and
these receptors are being recognized as important targets for general anesthetics
It has been demonstrated that nAChRs are tangled in cognitive processes such as
learning and memory and control of movement in healthy subjects.
19
NERVOUS SYSTEM - GERIATRIC POPULATION
Memory decline occurs in greater than 40% of individuals older than age 60 years. 13
Memory decline in aging is not inevitable, however age-related memory decline is
important because it can dramatically affect performance of the activities of daily living .
Structurally, cerebral atrophy occurs with aging in a selective and differential manner.
There is a shrinkage in the volume of gray and white matter14. The decrease in gray
matter volume is thought to be secondary to neuronal shrinkage as opposed to neuronal
loss. More recent studies focusing on the effects of normal aging on the human cerebral
cortex suggest that there is a small overall loss of neurons from the neocortex15
Some neocortical areas do not lose any neurons with aging. There may be 15% loss,
however, of white matter with aging.15 Such loss results in gyral atrophy and increased
ventricular size. Shrinkage in the subcortical white matter and the hippocampus may be
accelerated by hypertension and vascular disease.
It is controversial whether the aging process alters the number of synapses present in the
cortex. Data suggests a significant regional reductions in the neurotransmitters dopamine,
acetylcholine, norepinephrine, and serotonin with aging.15 Levels of glutamate, the primary
neurotransmitter in cortex, do not seem to be affected. Coupling of cerebral electric activity,
cerebral metabolic rate, and cerebral blood flow remains intact in elderly individuals.
Decreases in brain reserve are manifested by increased sensitivity to anesthetic
medications, increased risk for perioperative delirium, and increased risk for postoperative
cognitive dysfunction.
20
DEFINITION – COGNITION16
Cognition is described as the mental processes of perception, memory, and information
processing, which permits the individuals to acquire knowledge, solve problems, and plan
for the future.
It encompasses the mental processes needed for everyday living and should not
be confused with intelligence.
Cognitive dysfunction is the impairment of these processes.
POST OPERATIVE COGNITIVE DYSFUNCTION:
The concept of postoperative disturbance in cognition has often been referred to as
postoperative cognitive dysfunction (POCD).5
The term is, is useful to distinguish among three types of cognitive deterioration after
surgery:
1. Delirium is usually easily recognized, being an important condition with fluctuating
course, characterized by change in level of consciousness and primarily disturbance
in attention. The duration is inconstant and the degree of severity ranges from mild
to very severe.
2. Short-term cognitive disturbance may be notable in the days following surgery.
This occurs relatively regularly and may be due to a combination of factors, including
surgery and anesthetic agents. This cognitive disturbance is short term, and it does
not persist beyond a few days after surgery. It is best assessed be
21
neuropsychological assessment, but frequently screening tests such as the Mini
Mental State Examination (MMSE) are used.
3. True POCD is a subtle decline in cognitive function , lasting for weeks, months, or
longer; and neuropsychological testing is required for verification. It can be
estimated to be a mild cognitive disorder characterized by impairment of memory,
learning difficulties, and reduced ability to concentrate.
22
HISTORY
Incidence and Risk Factors concerning Postoperative Cognitive
Dysfunction after Noncardiac Surgery
The incidence of POCD in elderly patients on the first day after minor surgery is more
than previously reported for 7 days after major surgery.
The earliest study is that of Bedford performed in 1955. It is a remarkable study that began
work in the field, but it is important that his findings were based on subjective observation
and questioning of relatives or caretakers. Using these techniques he reported that 7%
(18/251) of elderly patients older than age 65 years became “demented after undergoing
general anesthesia.
Subsequently, Simpson and associates17 reported no significant connection between
anesthesia and decreased mental performance in 620 elderly patients, whereas Blundell
and colleagues18 found a significant deterioration in 50% of tests after surgery in 51 patients
aged 70 and older.
In a comprehensive research of 98 subjects with an average age of 73 years, Ancelin and
associates19 found decline in 1 test of 28 in 71% of subjects 9 days following surgery and
in 56% of subjects at 3 months.
Grinchnik and coworkers20 found POCD in 45% of a representation of 29 patients with a
mean age of sixty years at 6 to 12 weeks after thoracic or vascular surgery. The definition
of POCD was similar to earlier studies in cardiac surgery, using a 20% deterioration in 20%
of the tests.
Further evidence that POCD does exist after noncardiac surgery was provided by Williams-
Russo and colleagues, 21 who reported POCD in 5% of 231 subjects older than
23
age 65 at 6 months after knee replacement. In this study POCD was determined
by a panel allowing on what constituted a "clinically important deterioration" in each of the
concerned tests; however, there was no control group to allow a comparison. One of the
important criticisms of these studies is that they investigated a simple incidence using a
conventional definition but failed to include any control group.
An international trial “The International Study on Postoperative Cognitive
Dysfunction (ISPOCD) of elderly patients” (mean age 68 years, range: 60-81 years) who
undertook noncardiac surgery demonstrated a 26% incidence of POCD 1 week after
surgery, with 10% having persistent POCD 3 months later 22 .
Postoperative cognitive deficits are common in adult patients of all ages at
hospital discharge, but only the elderly are at substantial risk for long-term cognitive
problems.
In this latter study, on discharge, POCD was present in 36.6% of young patients
(18-39 years), in 30.4% of middle-aged (40-59 years) and in 41.4% of elderly patients (60
years or older), while at 3 months after surgery, it was present in 5.7% young patients,
5.6% middle-aged, and 12.7% old aged patients .
Also, Lohom and colleagues 23 detected POCD more commonly in patients than
in controls, with 53% of patients exhibiting POCD at 6 weeks after laparoscopic surgery
compared with 23% of controls
24
Risk Factors for POCD after Noncardiac Surgery:
Multiple aetiologies, including age, preexisting cerebrovascular disease, prior
functional and American Society of Anesthesiology (ASA) status, urgency of operation,
regional versus general anaesthesia, have been proposed to explain cognitive impairment
but the risk factors are unknown and the severity of impairment is unpredictable .22
The biggest study was conducted by the ISPOCD2 group and included 508
middle- aged patients (40-59 years) and 185 control samples of similar age.24 Interestingly,
when the surgical patients were compared with a previous group older than 60 years they
attained the younger group showing significantly lesser POCD at both 7 days (P = .0064)
and 3 months (P = .026) following surgery.
Duration of anaesthesia, respiratory complications, infectious complications,
second operation, and level of education were all important factors in the ISPOCD1
study.22Although episodes of hypoxemia or hypotension have often been presumed to be
important, no statistically significant correlation with POCD was found in this study
Ancelin and associates19 found a correlation between postoperative cognitive
impairment and increasing age, low level of education, poor preoperative test performance,
depression, and type of anesthesia (general versus epidural). However, in another study by
Leung and coworkers25 no significant differences were found between types of general
anesthesia used or use of nitrous oxide.
25
TABLE 4: Predisposing and Precipitating Factors for Postoperative
Delirium:
Demographic characteristics—age >65 yrs. and male
Cognitive impairment or depression
Functional impairment
Sensory impairment, especially visual and hearing
Decreased oral intake
Drugs—polypharmacy, alcoholism, psychoactive, sedatives,
narcotics, anticholinergic
Comorbidity—severe illness and neurologic disease
Some types of surgery—high-risk surgery (American Heart
Association guidelines) and orthopedic
Intensive care unit admission
Pain
Sleep deprivation
Immobility/poor physical condition
Adapted from Inouye SK: Delirium in older persons. N Eng.
J Med 354:1157-1165
200626
26
Type of Surgery
Minor Surgery
Cataract surgeries were associated with a 1% to 3% incidence27 gastrointestinal
operations with a 17% incidence28, and orthopedic surgeries with a 28% to 62%29 incidence
of mental impairment.
POCD after 1 week appears to be much less common after minor surgery than
after major surgery. Numerous factors may be important in explaining this difference in
incidence of POCD, including the obvious difference in surgical trauma, postoperative
stress response, postoperative pain, and need for analgesia. There is some information to
suggest a correlation between the inflammatory response and the extent of recovery after
surgery. The incidence of cognitive dysfunction has been stated between 1% and 60%,
depending on the type of operation2.
Katherine P, Grichnik MD, Alexander JJ. jisselmuiden, Thomas AI studied
incidence, severity, and predictor for cognitive dysfunction after major thoracic and vascular
procedures. Twenty-nine patients who had thoracic and vascular procedures were studied.
A neurocognitive test battery was directed preoperatively and 6 to 12 weeks
postoperatively. A change score (preoperative minus postoperative) was calculated for
individual measure in each individual.
Cognitive deficit (a measure of incidence) was demarcated as a 20% decrement
in 20% or more of the completed tests. The incidence of cognitive deficit was
44.8%.Overall the
27
severity of the decay was an average of 15% decline. In 44.8% of patients who
had cognitive deficit, the severity was 24.7%.
The incidence of POCD following cardiac surgery (coronary artery bypass and/or
valve replacement or repair) has been reported as 50% to 70% in the first postoperative
week, 30% to 50% after 6 weeks, and 20% to 40% at months and 1 year .30
General Versus Regional Anaesthesia
If general anaesthesia is an important factor leading to the development of
POCD, then it would be expected that regional anesthesia would reduce the incidence.
Barnaby ward and colleagues31 study showed significant impairment of cognitive
function in the three days following GA, but not LA. 258 subjects undergoing general
anesthesia (GA) and 250 patients scheduled for local anesthesia (LA) were recruited from
ambulatory surgical unit. Patients were questioned to finish these cognitive failures
questionnaire (CFQ) before their procedures (with respect to the earlier three days) and on
the third postoperative day (with respect to their recovery period). The Median preoperative
CFQ scores (interquartile range) were 26 (18) for the LA group and 26 (18) for the GA group.
The Postoperative Cognitive failure questonnaire scores were 25 (20) for the LA subjects
and 28 (22) for the GA subjects. There was not statistically significant difference in
preoperative CFQ score between groups (Mann-Whitney). When preoperative and
postoperative CFQ scores were compared, the small increase seen in the GA group.
28
Neuropsychological Testing in Surgical Patients
Neuropsychological assesstments (NP tests) are used to objectively measure
cognitive function. A recent review of POCD studies in noncardiac surgery.32 indicated that
70 different NP tests had been used in this area in conjunction with 9 composite batteries,
with between 1 and 13 tests used per study. The domain most often assessed was memory
and learning.
The tests used in the detection of POCD, unlike those usually employed in a
clinical assessment, need to be sensitive to change.
Timing of Assessments
A very important issue regarding the measurement of POCD is the timing of the
assessments. The timings of preoperative assessments have varied widely in studies, with
some conducted within weeks of surgery, but many have been conducted at the time of
admission into hospital for surgery; this may be 1 day before surgery or even on the day of
their operation.
Cognitive problems are frequently observed in patients in the days immediately
after surgery and are often transitory.
These early assessments may well be detecting a transient disturbance of
cognition, and the assessments conducted within days of surgery are likely to be influenced
by general postoperative readjustment as well as analgesics, pain, and fatigue.
Assessments conducted later in the recovery period (approximately 4 weeks after surgery)
are likely to detect a persistent or permanent change. There is an indication that the early
predischarge assessments may predict longer-term decline.
29
MINI MENTAL SCORE EXAMINATION (MMSE)
The Folstein Mini-Mental State Examination (MMSE), developed in 1975 as a
bedside test of cognitive function, has been extensively used in clinical trail and research
and is widely accepted as a clinical tool for diagnosing and monitoring dementia33.
The MMSE was generated to distinguish between older individuals with or
without neuropsychiatric disorder initial in the disease processes. MMSE is also used
during follow-up of patients suffering from cognitive impairment to assess disease
progression
Folstein et al., 33 reported that the MMSE is highly reliable on 24 hrs. and 28-day
retest by single observers. They also summarized good inter-rater reliability for the MMSE
(r = 0.83) when the MMSE was examined by two different examiners 24 hours apart.
O'Connor et al., 34 summarized that 86% of subjects estimated to have organic
mental disesases obtain a score of twentythree or less on the MMSE and that 93% of those
subjects found have good cognitive function scored 24 or more.
The MMSE, an easily administered 30-point test of cognitive function, contains
tests of orientation, working memory (e.g., spell world backwards), episodic memory
(orientation and recall), language comprehension, naming, and copying.
The primary study to clarify MMSE factorial structure was by Fillenbaum et al 35. These
authors
asked the MMSE to 36 patients with a diagnosis of probable Alzheimer's disease (AD) at
its early stage. Factor analysis indicated that the composite score generated by multiple MMSE
cognitive components could be described by two factors.
The first factor included attention/concentration, language and constructional
30
praxis and the second is time-space orientation and delayed recall.
The Modified Mini-Mental State (3MS) 36 incorporates four added test items,
more graded scoring, and some other minor changes. These modifications are considered
to sample a larger variety of cognitive functions, cover a wider range of difficulty levels, and
improve the reliability and the validity of the scores. The 3MS retains the brevity, ease of
direction, and objective scoring of the MMS but expands the range of values from 0-30 to
0-100
31
TABLE 5: MMSE CHART33
32
TABLE 6: Interpretation of MMSE scores33
33
REVIEW OF LITERATURE
STUDIES COMPARING DESFLURANE AND SEVOFLURANE
Xiaoguang Chen, Manxu Zhao , Paul F. White1 evaluated the cognitive recovery profiles in
elderly patients after general anesthesia with desflurane or sevoflurane.
70 ASA physical status I,II,III consenting elderly patients (65 yrs. old) undertaking total knee
o rtotal hip replacement procedures were randomly assigned to one of two general
anesthetic groups. Both Propofol and fentanyl were given for induction of anesthesia
followed by either desflurane 2%–6%or sevoflurane 1%–1.5% with N20 66%in oxygen.
The Mini-Mental State (MMS) examination was used to assess cognitive function
preoperatively and postoperatively at 1, 3, 6, and 24-h intervals.
The usage of desflurane was correlated with a more rapid recovery from anaesthesia(6.3
+/- 2.4 mins versus 8.0 +/- 2.8 mins) and a shorter length of stay in the post anesthesia care
unit (213 +/- 66 min versus 241 +/- 87 min).
Sevoflurane subjects when the MMS scores were compared preoperatively, and
However, there were no significant differences between the Desflurane and the
postoperatively at 1, 3, 6, and 24 h.
J.E Heavener and colleagues 37 found Early recovery times but not intermediate recovery
times of elderly subjects undergoing a wide range of surgical procedures requiring two or
more hours of anesthesia is significantly faster after desflurane.
50 ASA physical status I- III patients, 65 years of age or older, undergoing anesthesia
supposed to last two or more hours were randomized to receive
34
desflurane/nitrous oxide or sevoflurane/nitrous oxide anesthesia. Patients were induced
with propofol 1.5-2.5 mg/ kg i.v. and maintained with either desflurane 2-4% or sevoflurane
0.6-1.75% with nitrous oxide 65% in oxygen.
Inspired anesthetic concentrations were adjusted to obtain adequate surgical anesthesia
and to maintain mean arterial pressure within 20% of baseline values. Early and
intermediate recovery times were recorded.
The times to extubating (5 (4-9); 9 (5-13) mins), eye opening (5 (3-5)mins; 11 (8-16) mins),
time to obeying commands (7 (4-9); 12 (8-17) mins); and orientation (7 (5-9); 16 (10-
21) mins) were significantly less (P<0.05) for desflurane than for sevoflurane.
Intermediate recovery, as measured by the digital symbol subtraction test and time to
ready for discharge from the PACU (56 (35-81)min; 71 (61-81) min) was similar in the
two groups.
R A Rortgen, D, Kloos J, Fries M38 concluded there was no difference in the incidence of
POCD with desflurane. However, according to the Paper-Pencil Tests, significant
improvements for the desflurane group could be detected (Well-being Test at 6-8 h, DST
at 6-8 h, and Trail Making Test at 66-72 h). Emergence was extremely significantly faster
in the desflurane group for 'time to open eyes' and 'time to extubation'
The primary result was the cognitive Test for Attentional Performance with its subtests
Alertness, Divided Attention, Visual Scanning, Working Memory, and Reaction Change. In
addition, Paper-Pencil Tests [Well-being Test BF-S, Recall of Digit Span (DST), Digit-
Symbol-Substitution Test, Trail Making Tests A and B, and Spielberg State-Trait Anxiety
Inventory were measured in this study.
35
In comparison with isoflurane, desflurane-based anesthesia appears to be superior, not
only in emergence, but also in recovery of cognitive functions 39. Recovery up to 45 minutes
postoperatively occurs earlier after desflurane, with significantly fewer impaired (i.e.,
drowsy, clumsy, fatigued or confused) patients40.
Recovery of cognitive function is similar with both desflurane and sevoflurane in patients
with and without morbid obesity 41 and anesthesia based on this anesthetic agent is
associated with a superior recovery – in terms of early time error product scores compared
with anesthesia with isoflurane.
Pensado Castineiras A, Rama Maceiras P, Molins Gauna N42 conducted a study to
compare the anesthetic maintenance and early postoperative recovery and psychomotor
function in patients who have been anesthetized with desflurane, sevoflurane or isoflurane
during extended open urological surgery. Seventy-five patients were randomized to receive
desflurane, sevoflurane or isoflurane with N2O 60% for anesthetic maintenance. The
concentration of each drug was accustomed to maintain arterial pressure and heart rate +/-
20% of baseline. After the operation the anesthetics were withdrawn and times until eye
opening, spontaneous breathing, extubation and orientation were recorded. The groups
were equivalent with regard to demographic features, anesthetic maintenance, duration of
anesthesia and relative doses of the anesthetics used. The Recovery times in the operating
room were significantly shorter (p < 0.05) after anesthesia with desflurane and sevoflurane
than with isoflurane, with no significant differences between the desflurane and sevoflurane
groups (duration of anesthesia in min 198 +/- 90, 171 +/- 67 and 191 +/- 79; eye opening
7.6 +/- 3.7, 7.8 +/- 3.0 and 11.9 +/-4.5 ; time until extubating 7.8 +/- 3.0, 8.3 +/- 3.0 and
11.0 +/- 3.5 for desflurane, sevoflurane and isoflurane, respectively
36
Bilotta F, Doronzio A, Cuzzone V, Caramia R, Rosa G43 conducted a study to evaluate
early postoperative cognitive recovery and gas exchange patterns, after balanced
anesthesia with sevoflurane or desflurane, in overweight and obese patients undertaking
craniotomy for supratentorial expanding lesions. Fifty-six patients were sequentially
enrolled, and randomly assigned to 1 of 2 study groups to receive balanced anesthesia
with sevoflurane or desflurane. Cognitive function was assessed with the Short Orientation
Memory Concentration Test and the Rancho Los Amigos Scale. Preoperative cognitive
position was similar in the 2 treatment groups. Early postoperative cognitive recovery was
more deferred and Short Orientation Memory Concentration Test scores at 15 and 30
minutes postanesthesia were lower in patients receiving sevoflurane-based anesthesia
than in those receiving desflurane-based anesthesia (21.5+/-3.5 vs. 14.9+/-3.5) (P<0.005)
and (26.9+/-0.7 vs. 21.5+/-1.4).
Agoliati A, Dexter F, Lok J, Masursky D,42 conducted a meta analysis of difference of
time to extubation comparing desflurane with isoflurane or isoflurane with sevoflurane
results showed Desflurane condensed the mean extubation time by 34% and reduced the
variability in extubation time by 36% relative to isoflurane. These reductions would diminish
the incidence of prolonged extubation times by 95% and 97%, respectively. Sevoflurane
decreased the mean extubation time by 13% and reduced the SD by 8.7% relative to
isoflurane. These reductions would diminish the incidence of prolonged extubation times by
51% and 35%, respectively
37
E iannuzzi, M iannuzzi, G viola,45 investigated pulmonary wash-out of sevoflurane and
desflurane and the quality of recovery from anesthesia in elderly patients.
The FA/FA0 ratio was lower in the desflurane group after halogenated agent suspension.
Desflurane showed to have a faster wash out curve with respect to sevoflurane.
Early recovery, as indicated by the time necessary to properly answer simple questions
after the discontinuation of anesthetics, showed a significant advantage for desflurane. VAS
was more in the desflurane group as well as the needs for postoperative analgesia.
S Gergin, B Cervik, G B yildrium46 concluded intraoperative cardiovascular stability was
simply achieved with both sevoflurane and desflurane, with MAP and HR maintained at +/-
20% baseline values during the maintenance period. Although HR reduced below baseline
values, decrease was less in desflurane group.
In conclusion, desflurane like sevoflurane maintains haemodynamic stability during intraop
period. Although duration of anesthesia was longer early recovery profile was rapid in
desflurane group. Differences in late recovery were comparable between the groups.
Solca M, Salvo I, Russo R, Fiori R, Veschi G47 concluded Early recovery in elderly
patients was rapid after desflurane than isoflurane anaesthesia; this might contribute to
increased requirement of postoperative analgesia. Only 24 patients (12 in desflurane and
12 in isoflurane group) require postoperative fentanyl administration; among them,
requirement was significantly more in desflurane patients (3.4 +/- 1.1 vs 2.4 +/-1.3
micrograms.kg-1. Total duration in recovery room was not different between anesthetics,
as well as adverse event prevalence and severity
38
MATERIALS AND METHODS
SOURCE OF DATA:
This is a randomized study of 100 consecutive patients undergoing elective surgical
procedure under general anesthesia in government general Hospital, kakinada, satisfying
the inclusion and exclusion criteria. The study period was from august 2016 to October
2018. Ethical clearance was obtained for those patients who underwent the study.
INCLUSION CRITERIA:
Patients above 65 years of age
ASA physical status I,II,III
Patients undergoing surgeries under GA lasting from 45 min upto 3 hours
EXCLUSION CRITERIA:
Patients who underwent general anesthesia in the past seven days
Patients with h/o neuropsychiatric disorders
Patients with h/o alcohol consumption.
Patients with significant cardiovascular, respiratory, hepatic, renal, neurological,
psychiatric, metabolic disease,
Patients with BMI > 30
patients unable to read and write
Patients with impaired hearing
Surgeries that required a Trendelenburg position
39
METHOD OF COLLECTION OF DATA:
100 patients above 65 years of age who were undergoing elective surgical procedures
under general anaesthesia were taken.
In the preoperative holding room, the Mini-Mental State Examination (MMSE) test was
performed.
The MMSE is a screening test that asses the cognitive impairment by asking patients a
variety of questions by quantitatyively.
The determined MMS value is 30 points, with scores of 23 or less being indicative of
cognitive impairment. The criterion used to describe a deterioration in cognitive functions
in our design was a decrease of two or more points on the MMS test correlated to the pre-
op value.48,1
Patients were randomized to two groups by using a computer-generated table.
The patient arrived in the operating room on the day of surgery, an intravenous infusion of
RL was started at 100 ml/hr., and monitors like NIBP, electrocardiogram (ECG), Pulse
oximeter were applied. All patients received the midazolam 1 mg IV for preoperative
medication,
Anaesthesia was induced with fentanyl, 1.0–1.5 mcg/kg IV, and propofol, 1.0–2.0 mg/kg
until loss of response to oral commands. Subsequently loss of consciousness, patients
received either Desflurane 5% or sevoflurane 2% (volume percent) through the tec6 and
tec7 vaporizer.
Endotracheal intubation was facilitated with vecuronium 0.1mg/kg . Maintainence of anesthesia by
sevoflurane 1-1.5% or desflurane 2-6% in mixing with N2O 66% in oxygen which resembled to 1-1.8
Mac (Age adjusted mac)49
40
NIBP, HR and oxygen saturation were recorded before induction of anaesthesia then, along
with end-tidal carbon dioxide, every 2 min after induction of anaesthesia for 15 min and
then every 5 min until the end of surgery. Temperature was monitored and was maintained
at 36 deg centigrade.
Inspired volatile anesthetic concentration was adjusted as necessary to maintain pulse and
NIBP within 20% of pre-induction values. If sudden rise occurres, the inspired concentration
of desflurane/sevoflurane was raised up to 50%. additional doses of fentanyl, 0.5–1.0
mcg/kg IV (to maximum dose of 200 mcg), was used to control sudden changes that did
not respond to two back-to-back 50% raises in the inspired gas concentration of
desflurane/sevoflurane or if there were any other signs of inadequate analgesia. Patients
who required a higher inspired inhalational agent concentration and patients who became
hemodynamically unstable during the procedure were excluded from the study.
vecuronium were given during the maintenance period. All patients received
inj.paracetamol infusion 15 mg/kg during intra operative period.
In the maintainence, ventilation was controlled to maintain normocarbia using a closed
circle system with a total fresh gas flow rate of 8 L/min.
Ten minutes before the predicted end of surgery the inhaled anesthetics were decreased to
0.5 MAC.After the completion of surgery, remaining neuromuscular block was reversed using
glycopyrrolate, 10mcg/kg IV, and neostigmine, 50 mcg/kg IV, Sevoflurane or desflurane was cut-off at
the start of skin closure, and N2O was cut-off at the end of surgery. Lungs were aerated with 100%
O2 at a fresh gas flow rate of 8 L/min.
41
The times from cut-off N2O to eye opening, tracheal extubation, following commands
(e.g., squeeze the investigator's hand), and the time to orientation to name and place
were assessed at 30–60 s intervals. The duration of surgery (from surgical incision to
skin closure) and anaesthesia (from the start of induction to discontinuation of N2O)
were also entered.
At 1, 3, 6 hours after the completion of anaesthesia, the patient's cognitive
functions were assessed by asking them to repeat the MMSE .
Adverse side effects like headache, dizziness, drowsiness, nausea, vomiting, anxiety,
restlessness were recorded.
42
STATISTICAL ANALYSIS
Student’s t-test was done for continuous variables, and paired Student’s t-test was applied
to compare the intragroup variations in the MMS scores at different assessment points with
their baseline values.
Categorical data were analyzed by chi square test. A value of P< 0.05 was regarded as
statistically significant. This information are presented as mean values , numbers or
percentages.
43
OBSERVATION AND RESULTS
TABLE 7 : AGE DISTRIBUTION AMONG THE TREATMENT GROUPS:
N Mean Std. ‘t’ ‘p’
Age Deviation value value
Sevoflurane 50 69.47 4.416
Desflurane 50 69.17 4.728 0.065 0.800
FIG 1 :AGE DISTRIBUTION AMONG THE

TREATMENT GROUPS
69.47
69.5
69.4
69.3
69.17
69.2
69.1
69
SEVOFLURANE DESFLURANE
There was no statistacally significant difference in age between the two groups.
44
TABLE 8 : SEX DISTRIBUTION AMONG THE TREATMENT GROUPS:
Gender
Treatment Group Total
Male Female
33 17 50
Sevoflurane
66.0% 34.0% 100.0%
20 30 50
Desflurane
40.0% 60.0% 100.0%
53 47 100
Total
53.0% 47.0% 100.0%
Chi-Square Value df ‘p’ value
3.270 1 .071
FIG 2 :GENDER DISTRIBUTION AMONG

THE TREATMENT GROUPS
100%
90%
80% 17
70% 30
60%
50%
40%
30% 33
20% 20
10%
0%
male female
sevoflurane desflurane
There was no statiscally significant difference in gender between the two groups.
45
TABLE 9: ASA GRADING BETWEEN THE TREATMENT GROUPS:
ASA Grade
Grade 2 Grade 3
35 15 50
Sevoflurane
70.0% 30.0% 100.0%
40 10 50
Desflurane
80.0% 20.0% 100.0%
75 25 100
Total
75.0% 25.0% 100.0%
.800 1 .493
FIG 3: ASA GRADING BETWEEN THE TREATMENT GROUPS

90%
80%
80%
70%
70%
60%
50%
40%
30%
30%
20%
20%
10%
0%
ASA GRADE 2 ASA GRADE 3
There was no statisticaliy significance with respect to ASA grading
between the two groups.

46
TABLE 10: TYPE OF SURGERIES BETWEEN THE TWO TREATMENT
GROUPS:
Treatment Group
Ortho Surgery Urology TOTAL
17 25 8 50
Sevoflurane
34.0% 50.0% 16.0% 100.0%
15 30 5 50
Desflurane
30.0% 60.0% 10.0% 100.0%
32 55 13 100
Total
32.0% 55.0% 13.0% 100.0%
8.806 4 .066
FIG 4 :TYPE OF SURGERIES
60%
30% 50%
60%
34% 10%
40%
16% DESFLURANE
20%
SEVOFLURANE
0%
ORTHO SURGERY UROLOGY
There was no significance with respect to type of surgeries between the groups
47
TABLE 11: COMPARISION OF MEAN DURATION OF ANESTHESIA AND
SURGERY BETWEEN THE TWO TREAMENT GROUPS:
Treatment N Mean Std. ‘t’ ‘p’
Groups Deviation value value
Duration of Sevoflurane 50 144.40 16.92

1.437 0.153
Anesthesia Desflurane 50 151.60 31.13
(min)
Duration of Sevoflurane 50 127.20 17.38

0.680 0.497
Surgery (min) Desflurane 50 119.17 28.35
FIG 5:MEAN DURATION OF ANAESTHESIA AND SURGERY BETWEEN

THE TWO GROUPS
127 119
200
144 151
150
100
DURATION OF SURGERY
50
DURATION OF ANAESTHESIA
0
DURATION OF ANAESTHESIA DURATION OF SURGERY
There was no statistical significance with regard to duration of anesthesia and
surgery between the groups

48
TABLE 12: COMPARISION OF MEAN PROPOFOL AND
FENTANYL REQUIREMENTS IN THE TREATMENT GROUPS:
Treatme N Mean Std. ‘t’ ‘p’
nt Deviation value value
Groups
PROPOFOL (mg) Sevoflurane 50 104.80 15.42
Desflurane 50 104.40 17.40 0.121 0.903
FENTANYL (ug) Sevoflurane 50 120.80 21.56
Desflurane 50 122.80 17.96 0.504 0.615
FIG 6:MEAN PROPOFOL AND FENTANYL REQUIREMENTS IN THE

TWO GROUPS
122.8
120.8
125
120
115
110 104.8 104.4

FENTANYL(mcg)
105
100
PROPOFOL(mg)
95
PROPOFOL(mg) FENTANYL(mcg)
There was no statistical significance with regard to mean propofol and fentanyl
requirements between the groups.

49
TABLE 13: COMPARISION OF RECOVERY INDICES BETWEEN THE
TREAMENT GROUPS:
Treatment N Mean Std. ‘t’ ‘p’

Eye Opening Sevoflurane 50 7.68 1.52
13.403 <0.001
(min) Desflurane 50 4.58 0.61
Extubation (min) Sevoflurane 50 9.68 1.35

13.388 <0.001
Desflurane 50 6.70 0.81
Commands (min) Sevoflurane 50 12.38 1.31

15.386 <0.001
Orientation (mm) Sevoflurane 50 14.20 1.26

13.655 <0.001
The times to eye opening, time until extubation, time to follow
commands and orientation to time, place was significantly better with
desflurane.
50
FIG 7:RECOVERY INDICES BETWEEN THE TREATMENT GROUPS
16
14.2
14
12.38
12 10.96
9.68
10 8.82
7.68
8 6.7
6 4.58
0
EYE OPENING(min) EXTUBATION(min) COMMANDS(min) ORIENTATION(min)
51
TABLE 14 : COMPARISION OF SIDE EFFECT PROFILE BETWEEN THE
TREATMENT GROUPS:
Side Effect
No Side effect Dizzinees Headach Nause Vomiting
e a
33 0 5 8 4 50
Sevoflurane
66.0% 0.0% 10.0% 16.0% 8.0% 100.0%
35 6 2 5 2 50
Desflurane
70.0% 12.0% 4.0% 10.0% 4.0% 100.0%
68 6 7 13 6 100
Total
68.0% 6.0% 7.0% 13.0% 6.0% 100.0%
5.858 4 .210
FIG 8:SIDE EFFECTS BETWEEN THE TREATMENT GROUPS
70%
80% 66%
60%
12% 10%
40% 4% 4%
16%
10% 8% DESFLURANE
20% 0%
SEVOFLURANE
0%
NO SIDE DIZZINESS HEADACHE NAUSEA VOMITING
EFFECT
The side effects between both the treatment groups were not statistically significant.
52
TABLE 15: COMPARISION OF POST OP ANALGESIC REQUIREMENT
BETWEEN THE TREATMENT GROUPS:
Post of Analgesia Given

No Yes
34 16 50
Sevoflurane
68.0% 32.0% 100.0%
35 15 50
Desflurane
70.0% 30.0% 100.0%
69 31 100
Total
69.0% 31.0% 100.0%
.077 1 .781
FIG 9:POST OP ANALGESIC REQUIREMENT
68% 70%
70%
60%
50%
40% 32% 30%
30%
20%
10%
0%
NO YES
Only 31% of the patients required tramadol postoperatively and it was found not to be statistically
significant.
53
TABLE 16:TREND OF MMSE SCORES OVER TIME:
A change in MMSE of -2 or more was taken as post operative cognitive
dysfunction. 0 corresponds to the preoperative MMSE.
Treatment MMSE 1 hr Change from Baseline Total
-5 -4 -3 -2 -1 0
Group
Sevofluran 2 `4 4 16 24 0 50
e 4.0% 8.0% 8.0% 32.0% 48.0% 0.0% 100.0%
Desflurane 0 8 14 10 15 3 50
0.0% 16.0% 28.0% 20.0% 30.0% 6.0% 100.0%
Total 2 12 18 26 39 3 100
2.0% 12.0% 18.0% 26.0% 39.0% 3.0% 100.0%
Chi-Square Value df 'p' value
7.685 5 .174
54
Treatment MMSE 3 hr Change from Baseline Total
-4 -3 -2 -1 0
Group
Sevoflurane 1 2 5 30 12 50
2.0% 4.0% 10.0% 60.0% 24.0% 100.0%
Desflurane 0 4 4 30 12 50
.0% 8.0% 8.0% 60.0% 24.0% 100.0%
Total 1 6 9 60 24 100
1.0% 6.0% 9.0% 60.0% 24.0% 100.0%
Chi-Square Value df 'p' value
2.767 4 .598
55
Treatme MMSE 6 hr Change Total
nt Group
from Baseline
-2 -1 0
Sevoflurane 2 13 35 50
4.0% 26.0% 70.0% 100.0
Desflurane 0 8 42 50
0.0% 16.0% 84.0% 100.0
Total 2 21 77 100
2.0% 21.0% 77.0% 100.0
Chi-Square df 'p’
Value value
1.958 2 .376
56
TABLE 17:COMPARISION OF MEAN MMSE SCORES BETWEEN THE
TWO GROUPS:
Treatment N Mean Std. 't' 'p'
Preop- Sevoflurane 50 29.30 0.68 0.37 0.710
Desflurane 50 29.24 0.92 2
MMSE
MMSE- Sevoflurane 50 27.38 1.24 1.12 0.263
Desflurane 50 27.06 1.58 3
1 hr
Desflurane 50 28.24 1.30 1
3 hr
Desflurane 50 29.12 1.02 8
6 hr
57
FIG 10:TREND OF MMSE SCORES OVER TIME
29.5
29
28.5
28
27.5
27
26.5
26
25.5
PREOP MMSE MMSE 1hr MMSE 3hr MMSE 6hr
Trend of MMSE scores shows that MMSE scores at 1 hr were
significantly low in both groups, but returned to the baseline by 6 hrs
58
TABLE 18:COMPARISION OF PERCENTAGE OF PATIENTS HAVING POCD
TRETMENT POCD at 1hr POCD at 3 hr POCD at 6hr
GROUP
sevoflurane 26 (52%) 8(16%) 2(4%)
desflurane 32(64%) 8(16%) 0
p value 0.44 0.71 0.31
FIG 11:POCD BETWEEN THE TWO GROUPS
64%
70%
52%
60%
50% 16%
40%
30% 16% 0%
DESFLURANE
20% 4%
10% SEVOFLURANE
0%
POCD 1hr POCD 3hr POCD 6hr
64% of patients in the desflurane group and 52% of the patients in the sevoflurane
group experienced cognitive dysfunction at the end of 1 hour, it persisted in 16% of
desflurane group , 16% of sevoflurane group by the end of three hours. However 96%
of the patients in the study reached almost baseline mmse scores by the end of 6
hrs.
59
POCD 1hr
42%
58% PRESENT
ABSENT
POCD 3hr
16%
PRESENT
ABSENT
84%
POCD 6hr
2%
PRESENT
ABSENT
98%
60
DISCUSSION
Despite advances in surgical and anesthetic techniques, surgery in the elderly
population can still be associated with significant postoperative morbidity and mortality 50.
Brain function is clearly affected during the immediate period after anesthesia,
with depressed level of consciousness and impairment of attention, memory, and reaction
time often being reported. Patients may experience complete amnesia for several hours
after general anesthesia in spite of being apparently completely awake.
The duration of the recovery of cognition after anesthesia and surgery is
depends on several factors and among other factors is dependent on the type of anesthesia
used, the type of surgery, and the patient. In some individuals, cognitive recovery is fast
(within a matter of hours), whereas, in others, brain function may be disturbed for a much
longer time.
The purpose of our study was to compare the speed of recovery in elderly
patients undergoing general anesthesia with sevoflurane or desflurane and to compare the
incidence and duration of cognitive impairment in them .
Postoperative cognitive impairment is a condition characterized by diminishing
of concentration and memory, and the occurance of pocd has been reported to be
extremely frequent in elderly patients. The aged brain is distinct from the younger brain in
several
important aspects, including size, distribution and different types of
neurotransmitters, metabolic function, and capacity for plasticity. For this reason, early
POCD is more common in the elderly after major operations, compared to middle-aged
61
patients52.Mean age in our study population was sixty nine years.
The pathogenesis of postoperative cognitive dysfunction is unclear; however,
age, alcohol abuse, hypoxia, hypotension, low baseline cognition and type of surgery have
been alleged to contribute to this problem.2
The choice of anaesthetic drugs can also affect postoperative cognition because
residual levels of volatile anaesthetics can produce changes in central nervous system
activity 53,54 Use of anaesthetics with a quick clearance and negligible metabolism may offer
advantages in this patient population. The v o l a t i l e anaesthetics desflurane and
sevoflurane possess low blood-gas partition coefficients, contributing to a faster early
recovery from anaesthesia compared with the traditional volatile anesthetics.55,39
subjects in our study were randomized onto two groups, to receive
desflurane or sevoflourane.
The two anesthetic groups were also comparable with respect to demographic
variables like age, gender, ASA grade , durations of anesthesia and surgery, as well as
doses of medications used for premedication, propofol induction dose , intra operative
analgesic requirement.
In addition, there were no significant differences in the amounts of
postoperative analgesic and the occurance of side effects in the two study groups.
The emergence times from the completion of anesthesia to eye opening,
tracheal extubation, following oral commands, and orientation were significantly shorter in
the Desflurane (versus Sevoflurane) Group .(P< 0.001) consistent with earlier studies .The
mean time to eye opening were (4.58 min vs 7.68 min) tracheal extubation (6.70 min vs
62
9.68 min) time to respond to verbal commands(8.82 min vs 12.38 min)and time to
orientation (10.96 min vs 14.20min) for desflurane and sevoflurane in our study.
Pensado Castiñeiras42 reported early post operative recovery with
desflurane with mean times to eye opening 7.6 , 7.8 min, time until extubation 7.8 ,
8.3min. for desflurane and sevoflurane.
Heavner and colleagues37 found Early but not intermediate recovery times of
elderly patients significantly faster after desflurane. They did not find any difference
between desflurane and sevoflurane in the elderly after general anaesthesia when they
were assessed with the Digit–Symbol Substitution Test.
In a study comparing desflurane and sevoflurane for the maintenance of anesthesia,
Nathanson et al 29 Observed earlier eye opening and decreased time to tracheal extubation with
the use of desflurane compared with sevoflurane. Analogues to the findings in this earlier study,
the late recovery profiles and incidences of postoperative side effects were similar after
desflurane and sevoflurane.
As a result of the lower solubility of desflurane (versus sevoflurane) in blood and lean
tissues, one might expect to find differences in the intermediate and late recovery end points
when these two anesthetics are used for longer surgical procedures. Eger 38 in a study found
that for a given duration of anesthesia, elimination was faster and recovery was quicker for
desflurane. Other studies 40-43 have found that only early recovery was faster with desflurane
compared to sevoflurane even when the duration of surgery exceeds 2 hours. Furthermore, the
63
recovery of psychomotor and cognitive function after desflurane and sevoflurane administration
were similar after the first 30-45 min in both younger patients undergoing ambulatory surgery
and elderly patients undergoing more prolonged general anesthesia for inpatient procedures.
Gergin 44 studied the hemodynamics, emergence and recovery characteristics of
sevoflurane with those of desflurane in nitrous oxide anesthesia and concluded that the groups
did not differ in these hemodynamic measures. However, a study by Elbert 45 concluded that
neurocirculatory excitation seen with rapid increase in desflurane did not occur with sevoflurane.
At steady state, increasing the concentration of sevoflurane was associated with lower
sympathetic nerve activity and central venous pressure.
The incidence of other postoperative complications (postoperative nausea and
vomiting, headache, drowsiness) was also similar in both groups. This was in contrast with to a
study by karlsen 46 who found that the postoperative nausea/vomiting rate was higher in the
desflurane group (67%) than that in sevoflurane group (36%).
Ravi Jindal 1 studied the comparison of maintenance and emergence characteristics
after desflurane or sevoflurane in outpatient anaesthesia and concluded that both desflurane
and sevoflurane groups had rapid recovery. There was a significant difference in the emergence
and early recovery between two groups. The early recovery was faster with desflurane
compared to sevoflurane. Although there was difference in intermediate recovery time, the
magnitude of the difference was small and insignificant.
64
In a study conducted by Amandeep Kaur 47 on hemodynamic and early
recovery characteristics of desflurane versus sevoflurane in bariatric surgery, concluded
that early postoperative recovery was significantly rapid after desflurane anesthesia and
patients could be transferred to PACU earlier. The intermediate recovery as evaluated by
Modified Aldrete score at 5 minutes and the DSST also occurred earlier in the desflurane
group. A meta analysis 44 on post operative recovery after GA also approves that subjects
receiving desflurane followed commands, were extubated, and were oriented 1.0- 1.2
minutes earlier than subjects receiving sevoflurane.
It has been shown by Bailey 56 that, after anesthesia administration of
intermediate duration (90 minutes), the 80% decrement times (time needed for 80%
decrease in anesthetic concentration) of desflurane and sevoflurane are nearly 5 minutes,
regardless of the duration of anesthesia. The major differences in the rate at which
desflurane and sevoflurane are eliminated occur in the last 20% and 10% of the elimination
process. After 90 minutes of anesthesia administration the 90% decrement time for
sevoflurane increases significantly, while it remains less than 10 mins for desflurane.
65
POCD:
The clinical tools used to measure cognitive function after anesthesia have not
been systematized, and the timing of the measurements has varied widely in earlier studies
57
Standard psychometric tests were used to estimate cognitive ability in adults
require a more amount of time to administer, rendering them impractical in the
perioperative period. In addition to the MMSE, Digit-Symbol Substitution Test 37 , Short
Orientation43 Memory Concentration Test and paper pencil tests38 have all been used to
evaluate cognitive function in the elderly.
In our study, the MMS was selected because it combined a high validity and
reliability with brevity and ease of application (and completion) for elderly patients
undergoing surgery with GA.
This test concentrates on the cognitive aspect of mental function and eliminates
questions regarding mood and abnormal mental experiences.
The MMSE has high specificity for detecting mild cognitive impairment, and thus was
chosen for use in our study setting. We are not able to demonstrate a clinically significant
difference in MMSE one hour after anesthesia end in patients given sevoflurane and desflurane.
Despite the slightly greater likelihood of MMSE decrease one hour after anesthesia in
sevoflurane, we were not able to show an intergroup difference of at least 2 points. The small
decrease found at one hour was no longer present and MMSE had returned to baseline by 6
hours after anesthesia. Thus our results show only a minimal transient decrease in cognitive
function assessed by MMSE one hour after anesthesia with no clinically significant difference
between sevoflurane and desflurane when administered as in this setting.

66
Minhthy Meineke 52 studied cognitive dysfunction following desflurane versus
sevoflurane general anesthesia in elderly patients concluded that they not able to demonstrate
a clinically significant (at least 2 points) difference in MMSE one hour after anesthesia end,
which is titrated to moderate general anesthesia guided by processed EEG. The small decrease
found at one hour was no longer present and MMSE had returned to baseline by 6 hours after
anesthesia.
According to Anthony et al.58, the MMS test was 87% sensitive and 82% specific
in detecting dementia and delirium.
When compared with the preoperative baseline MMS values, the mean MMS
scores were significantly reduced at one hour postoperatively in both groups .
At 6 h postoperatively, all the patients (except two in the sevoflurane group) had
almost returned to their baseline MMS scores. There was no significant difference between
the Desflurane and the Sevoflurane groups with respect to their MMS score preoperatively
and at 1, 3, 6, h postoperatively.
A total of 32 subjects in the Desflurane group (64%) and 26 subjects in the
Sevoflurane group (52%) experienced significant decreases in cognitive function at 1 h
postoperatively. At 3 postoperatively, there were only 8 patients in the Desflurane group
(16%) and 8 patients in the Sevoflurane group (16%) with persistent decreases in their MMS
67
scores. Importantly, 100% of patients in the Desflurane group and 96% in the Sevoflurane
group demonstrated completely normal cognitive function at 6 h postoperatively.
Chen and colleagues,1 R A Rortgen38 and colleagues have also not found any
significant change in the post operative cognitive functions in desflurane and sevoflurane
groups.
We tested cognitive function in elderly patients undergoing surgery with lower
risk of cognitive dysfunction. If we had used high-risk operations such as cardiac surgery,
where the incidence of early neurocognitive deficit is as high as 80%, the results might have
been different59.
The early recovery profiles (e.g., 0–4 hr) of modern anesthetics such as
sevoflurane, desflurane and propofol have been well studied and freshly reviewed. Most
psychometric tests appear to show a return to baseline values between four and six hours
after anaesthesia,60,61
Although postoperative mental dysfunction is well recognized in elderly patients
, the duration of the impairment has been somewhat controversial .
In a follow-up study, Abildstrom and colleagues 62 reported that postoperative
cognitive dysfunction was a reversible condition in the majority of cases, but may persist in
approximately 1% of elderly patients. Of importance, cognitive impairment in the early
postoperative period was a significant risk factor for long-term cognitive dysfunction.
The absence of a significant difference between two groups does not exclude
68
the possibility that a more sensitive test of cognitive function might demonstrate a difference
between the two volatile anaesthetics
69
SUMMARY
This study was performed to compare the speed of recovery and the incidence and
duration of cognitive impairment in elderly patients undergoing general anesthesia with a
sevoflurane/desflurane based technique.
100 patients above the age of 65 years were randomly allocated into the two
groups. Recovery in these patients was studied in relation to variables like:
Time to eye opening
Time until extubation
Time to follow commands
Time to orientation to time.
Cognitive status of the patient was assessed with mini mental score examination
preoperatively and at 1,3, 6 hrs postoperatively.
Desflurane was associated with a faster early recovery than sevoflurane in elderly
patients
in this study 64% of subjects in the desflurane group and 52% of the subjects in the
sevoflurane group experienced cognitive dysfunction at the end of 1 hour, it persisted in
16% , 16% of them by the end of three hours. However 96% of the patients in the study
reached almost baseline mmse scores by the end of 6 hrs.
70
CONCLUSION
Desflurane was associated with a faster early recovery than sevoflurane in elderly
individuals.
Recovery indices like times to eye opening, time until extubation, time taken to
follow verbal commands and time to orientation were significantly better in the desflurane
group .
Postoperative recovery of cognitive function was similar with both volatile
anesthetics. Most importantly, use of either sevoflurane or desflurane for maintenance of
anaesthesia in the elderly was associated with only transient cognitive impairment as
assessed by MMSE at 1 hr, with 96% of them returning back to their baseline cognitive
status 6 hrs postoperatively.
71
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halothane, enflurane, isoflurane or propofol anaesthesia. Br J Anaesth
1994; 72: 559–66.
61. Sanou J, Goodall G, Capuron L, Bourdalle-Badie C, Maurette P. Cognitive
sequelae of propofol anaesthesia. Neuroreport 1996; 7: 1130–2.
62. Abildstrom H, Rasmussen LS, Rentowl P, et al. Cognitive dysfunction 1–
2 yrs after non-cardiac surgery in the elderly. Acta Anaesthesiol Scand
2000;44:1246– 51.
79
ANNEXURES – 1
THESIS PROFORMA
CHARACTERISTICS AFTER DESFLURANE VERSUS
SEVOFLURANE ANAESTHESIA IN ELDERLY PEOPLE POSTED
FOR VARIOUS SURGICAL PROCEDURES UNDER GENERAL
ANAESTHESIA – A Prospective Randomized double blinded
clinical trial.”
NAME
DATE
SEX
AGE
WEIGHT
IP NUMBER
ASA STATUS
PREMEDICATION
PROPOFOL INDUCTION DOSE
INTRA OP FENTANYL REQUIREMENT
TOTAL FENTANYL DOSE
DURATION OF ANESTHESIA
DURATION OF SURGERY
TYPE OF SURGERY
80
PREOPERATIVE MMSE
TIME TO EYE OPENING
TIME TO EXTUBATION
TIME TO FOLLOW ORAL COMMANDS
TIME TO ORIENATION
MMSE AT 1 HR
MMSE AT 3 HRS
MMSE AT 6 HRS
SIDE EFFECTS
POSOP ANALGESIC REQUIREMENT
81
82
CONSENT FORM
INFORMED CONSENT FORM
PROTOCOL No:
PROCEDURES UNDER GENERAL ANAESTHESIA – A Prospective Randomized
double blinded clinical trial.”
PATIENT ID No:
NAME: ––––––––––––––––––
AGE: –––––––––––––––––– SEX: –––––––––––––
ADDRESS: –––––––––––––– PHONE No: –––––––––––––––––––
1. PURPOSE OF THESTUDY
To compare the speed of recovery in elderly patients undergoing general anesthesia with
sevoflurane or desflurane. To determine the incidence and duration of cognitive impairment
in elderly patients undergoing general anesthesia with a sevoflurane or desflurane-based
technique
2. DRUGDESCRIPTION:
83
Sevoflurane and desflurane agents are potent volatile inhalational agents .
3. STUDY APPROVAL:
This study has been approved by institution ethics committee Rangaraya medical college,
Kakinada, to ensure that the rights of humans are protected.
This study will be conducted by Dr.ARASAVALLI SIVANWESH under the supervision of
Dr.T.PREM SAGAR M.D.
4. PROCEDURE TO BEFOLLOWED:
In the study you will be examined clinically. If you fulfill inclusion and exclusion criteria
and accept to get enrolled in the study and you will be allocated in one of the Procedure.
5. BENEFITS:
Recovery indices like times to eye opening, time until extubation, time taken to follow
commands and time to orientation were significantly better in the desflurane group .
6. CONFIDENTIALITY OFREPORTS:
All the medical records in the study will be kept in confidential. The drug regulatory
authorities and IEC can examine if necessary.
7. HELPLINE:
In case of any problem you contact Dr. ARASAVALLI SIVANWESH on phone number
8500730742. You will receive prompt and appropriate medical attention.
8. RIGHT TO WITHDRAW FROM THESTUDY:
You are free to withdraw your consent to participate in this study at any time without
84
giving reasoning.
9. ADDITIONALINFORMATION:
You are entitled to ask questions at any time during your participation in the study. You
will be given a copy of this agreement for your own record.
10. RESPONSIBILITY:
In case of any complications due to the study drug and procedure. The investigator will
bear the compensating responsibility.
11. FINANCIAL CONSIDERATION:
You will not any complications for the inconvenience caused by your voluntary
participation in the study site etc.
Signatureofinvestigator Signature ofParent/volunteer
Dr.ARASAVALLI SIVANWESH
Department of Anaesthesiology Rangaraya Medical College, Kakinada.
Date: Date:
Signature ofthewitness: Relation ofPatient/volunteer Name:
Address of witness:
Date:
85
INFORMED CONSENT ACCEPTANCE SHEET
Department of Anaesthesiology
Rangaraya Medical College Kakinada, Andhra Pradesh
PROTOCOL No:
PROCEDURES UNDER GENERAL ANAESTHESIA – A Prospective Randomized
double blinded clinical trial.”
I have read the study protocol titled above and had an opportunity to ask questions
and all, u questions were answered in local language to my satisfaction. My participation
in the study is voluntary. I have the right to be provided with answers to questions arising
during course of study. I am aware of the adverse reactions of this medicine and I do not
held the doctors to be responsible. I am also aware of my right to withdraw from the study
at any time without assigning any reason. I am also aware that I can be dropped from the
study at any time without giving reasoning. I have given a copy of consent form.
My age is –––––––––
Signatureofinvestigator Signature of Parent/Volunteer

Department ofAnaesthesiology,
Rangaraya Medical College, Kakinada.
Date: Date:
Signature ofthewitness: Relation to Patient/Volunteer Name:
Address ofwitness:
Date:
86
S.NO NAME IP NO AGE SEX WEIGHT TYPE OF SURGERY ASA GRADING AGENT USED DURATION OF(min) PROPOFOL FENTANYL BASELINE HR HR
ANESTHESIA SURGERY (mg) (mcg) HR (5min) (10min)

1 K.Satyavathi 43224 69 female 56 lt modified radical mastectomy II SEVOFLURANE 140 120 100 120 90 93 78
2 Challayamma 43252 68 female 52 subtotal thyroidectomy II SEVOFLURANE 120 110 80 140 79 100 77
3 B.Maridamma 44724 72 female 50 rt modified radical mastectomy III SEVOFLURANE 150 130 110 100 88 90 89
4 G.Gangamma 43333 70 female 60 lt modified radical mastectomy II SEVOFLURANE 140 120 120 150 78 89 79
5 M.Peddakasuraju 44497 66 male 74 clavicle plate fixation II SEVOFLURANE 160 150 140 180 77 98 89
6 G.Mahesh 41819 69 male 54 pcnl III SEVOFLURANE 120 100 100 100 86 86 78
7 Ch. Subramaneswara swamy 46860 67 male 52 proximal humerus plating II SEVOFLURANE 180 160 110 100 80 82 90
8 P.Lakshmi narayana 44744 74 male 48 laterjet procredure-rec shoulder dislocation II SEVOFLURANE 150 140 90 120 80 78 98
9 G.Apparao 46279 67 male 64 truncal vagotomy and gastrojejunostomy III SEVOFLURANE 140 120 120 140 88 84 80
10 ch.venkata lakshmi 43234 69 female 56 laminectomy and discectomy II SEVOFLURANE 160 140 100 120 78 89 80
11 G.jayaram 44699 72 male 50 pcnl II SEVOFLURANE 120 100 90 100 87 90 90
12 P.Mangatayaru 47250 76 female 62 rt modified radical mastectomy III SEVOFLURANE 140 130 120 120 94 80 89
13 K.Satyanarayana 44486 66 male 54 clavicle plate fixation II SEVOFLURANE 160 140 110 120 88 94 98
14 M.naidamma 48490 67 female 50 subtotal thyroidectomy III SEVOFLURANE 150 130 100 100 78 86 90
15 B.Ashok kumar 50202 69 male 46 lateral pancreatico jejunostomy II SEVOFLURANE 140 120 90 100 77 90 90
16 G.venkata rao 43727 67 male 50 pcnl II SEVOFLURANE 120 100 80 100 89 98 90
17 A.Lovaraju 51126 69 male 64 proximal humerus plating III SEVOFLURANE 150 140 120 140 79 87 87
18 K.Kanakam 47749 70 male 56 laminectomy and discectomy II SEVOFLURANE 160 140 110 120 89 79 83
19 Ch.Sakkubhai 47752 66 male 78 pcnl II SEVOFLURANE 120 100 130 150 78 72 87
20 P.Moshe 44270 68 female 50 subtotal thyroidectomy III SEVOFLURANE 140 120 90 100 90 83 80
21 T.ramarao 46271 69 male 52 laterjet procredure-rec shoulder dislocation II SEVOFLURANE 150 140 100 120 98 82 87
22 G.Lakshmi 48562 67 female 50 lt modified radical mastectomy II SEVOFLURANE 130 120 90 100 80 94 88
23 S.naga venkata lakshmi 41914 67 female 52 rt modified radical mastectomy II SEVOFLURANE 140 120 110 140 80 80 102
24 B.lakshmana rao 49062 68 male 62 laminectomy and discectomy II SEVOFLURANE 180 160 120 140 90 92 88
25 j.kasthuri 50198 69 female 48 subtotal thyroidectomy III SEVOFLURANE 150 130 90 100 89 75 93
26 A.durga prasad 43871 74 male 46 pcnl II SEVOFLURANE 120 100 80 100 98 86 98
27 M.Babu Rao 45523 72 male 58 laminectomy and discectomy II SEVOFLURANE 150 140 120 140 90 74 98
28 Ch.devi 34383 80 female 56 rt modified radical mastectomy III SEVOFLURANE 160 140 110 120 90 79 98
29 krishna kumar 50255 68 male 62 pcnl II SEVOFLURANE 120 100 130 150 90 85 90
30 ch.gowri 46867 67 female 46 lt modified radical mastectomy III SEVOFLURANE 140 120 90 100 87 87 78
31 v.kiran kumar 16432 68 male 56 proximal humerus plating II SEVOFLURANE 150 140 100 120 83 83 88
32 k.gayathri 3446 66 female 45 lt modified radical mastectomy II SEVOFLURANE 130 120 90 100 87 86 78
33 B RAMARAO 7661 67 male 52 truncal vagotomy and gastrojejunostomy III SEVOFLURANE 140 120 110 140 80 80 89
34 L SITALAKSHMI 14312 68 female 64 laminectomy and discectomy II SEVOFLURANE 180 160 120 140 87 80 78
35 s.subbaraju 16147 68 male 46 gastrectomy and esophagojejunostomy II SEVOFLURANE 150 130 90 100 88 88 88
36 p.lakshmikantham 17144 67 female 50 subtotal thyroidectomy II SEVOFLURANE 140 120 100 120 102 78 78
37 N TULASI 17242 67 female 56 lt modified radical mastectomy III SEVOFLURANE 120 110 80 140 88 87 89
38 S GIRISH 17345 67 male 54 truncal vagotomy and gastrojejunostomy II SEVOFLURANE 150 130 110 100 93 94 89
39 N GANGARAJU 17453 74 male 64 retroperitoneal tumour II SEVOFLURANE 140 120 120 150 98 88 80
40 J RAMBABU 17547 70 male 52 proximal humerus plating III SEVOFLURANE 160 150 100 180 98 78 80
41 k.ravibabu 17562 67 male 70 pcnl II SEVOFLURANE 120 100 140 100 98 77 90
42 V VEERENDRA 17487 67 male 56 clavicle plate fixation II SEVOFLURANE 180 160 110 100 90 89 79
43 s.subbarao 17122 67 male 48 laminectomy and discectomy II SEVOFLURANE 150 140 90 120 78 79 88
44 y.nageswararao 17892 66 male 64 subtotal thyroidectomy III SEVOFLURANE 140 120 12 140 88 89 78
45 p.kumar 17232 71 male 52 laminectomy and discectomy II SEVOFLURANE 160 140 100 120 78 78 77
46 G PRADEEP KUMAR 17953 68 male 46 pcnl II SEVOFLURANE 120 100 90 100 89 90 86
47 K KOUSHIK 17957 69 male 62 truncal vagotomy and gastrojejunostomy II SEVOFLURANE 140 120 120 120 78 98 80
48 B RAKESH 18143 68 male 52 proximal humerus plating II SEVOFLURANE 160 140 110 120 88 80 80
49 P SUBBA RAO 18231 67 male 50 gastrectomy and esophagojejunostomy II SEVOFLURANE 150 130 100 100 78 80 88
50 k.ramakrishna 18254 68 male 48 subtotal thyroidectomy II SEVOFLURANE 140 120 90 100 89 90 78
51 j ramalakshmi 36967 66 female 44 lt modified radical mastectomy II DESFLURANE 150 120 80 100 89 89 87
52 v mangatayaru 48450 68 female 50 rt modified radical mastectomy II DESFLURANE 150 130 100 140 80 98 94
53 ch jhansi rani 48052 69 female 46 laminectomy and discectomy III DESFLURANE 180 160 90 100 80 90 88
54 g suresh 41148 70 male 58 laterjet procredure-rec shoulder dislocation II DESFLURANE 200 180 120 140 87 90 90
55 r govind babu 49374 72 male 48 pcnl II DESFLURANE 120 100 90 120 94 90 79
56 h venkata lakshmi 35449 68 female 50 subtotal thyroidectomy III DESFLURANE 140 120 100 120 88 87 88
57 b.naga durga 48523 74 female 42 lt modified radical mastectomy II DESFLURANE 100 90 80 100 78 83 78
58 h.bhaskar reddy 46260 68 male 70 clavicle plate fixation II DESFLURANE 180 160 140 160 77 87 77
59 b.atchayamma 50875 67 female 64 rt modified radical mastectomy III DESFLURANE 160 140 120 140 89 80 86
60 v.nageswararao 44764 68 male 45 proximal humerus plating II DESFLURANE 200 180 90 120 79 94 80
61 ch veraveni 51162 69 female 42 rt modified radical mastectomy II DESFLURANE 120 110 80 100 77 88 80
62 b.adhilakshmi 41112 70 female 60 laminectomy and discectomy II DESFLURANE 220 180 120 140 89 78 88
63 h.venkayamma 51384 72 female 54 lt modified radical mastectomy II DESFLURANE 140 120 110 120 79 77 78
64 g.veerabhadhram 43212 76 male 46 rt modified radical mastectomy II DESFLURANE 160 140 90 120 89 89 87
65 n.venkata chalam 50716 68 male 50 laminectomy and discectomy III DESFLURANE 180 150 100 120 79 79 94
66 g.uma devi 50899 69 female 62 subtotal thyroidectomy II DESFLURANE 120 100 120 140 90 77 88
67 k.durga reddy 42371 67 male 52 subtotal thyroidectomy II DESFLURANE 140 120 100 100 79 89 90
68 g p swamy 50906 70 male 45 proximal humerus plating II DESFLURANE 160 140 90 100 88 79 79
69 p bhaskar rao 45981 78 male 60 pcnl II DESFLURANE 120 100 120 140 78 89 88
70 k savithri 51411 68 female 50 rt modified radical mastectomy II DESFLURANE 100 80 100 120 77 79 78
71 r viswamitra 42364 69 male 60 laminectomy and discectomy II DESFLURANE 180 160 120 140 86 90 77
72 t gunavathi 52458 69 female 70 lt modified radical mastectomy III DESFLURANE 150 120 140 150 80 79 86
73 g.ganga bhavani 43529 68 female 45 lt modified radical mastectomy II DESFLURANE 160 140 90 100 80 88 80
74 k jayabhagavan 53808 69 male 50 pcnl II DESFLURANE 120 100 100 120 88 90 80
75 k suryakumari 49438 66 female 60 lt modified radical mastectomy II DESFLURANE 140 120 120 120 78 79 88
76 padmavathi m 46647 67 female 60 subtotal thyroidectomy II DESFLURANE 120 100 120 140 90 88 78
77 subbalakshmi h 49384 70 female 50 rt modified radical mastectomy III DESFLURANE 140 120 100 100 78 78 87
78 v mahalakshmi 44960 67 female 44 subtotal thyroidectomy II DESFLURANE 160 140 90 100 88 77 94
79 g nagababu 44964 68 male 62 pcnl II DESFLURANE 120 100 120 140 89 86 88
80 t eswaramma 49046 66 female 50 rt modified radical mastectomy II DESFLURANE 100 80 100 120 90 80 78
81 g siva kumar 17564 68 male 62 laminectomy and discectomy III DESFLURANE 180 160 120 140 80 80 77
82 ch chadramma 15408 69 female 72 rt modified radical mastectomy II DESFLURANE 150 120 140 150 80 88 89
83 g bhanumathi 17737 69 female 46 lt modified radical mastectomy II DESFLURANE 160 140 90 100 87 78 79
84 t annapurna 18563 70 female 52 lt modified radical mastectomy III DESFLURANE 120 100 100 120 83 87 89
85 e mangamma 18543 76 female 64 rt modified radical mastectomy II DESFLURANE 140 120 120 120 87 94 78
86 rangamma j 18694 68 female 42 subtotal thyroidectomy II DESFLURANE 150 120 80 100 88 88 90
87 h bharathi 19231 67 female 48 subtotal thyroidectomy II DESFLURANE 150 130 100 140 104 78 98
88 s annavaram 19285 68 male 46 clavicle plate fixation III DESFLURANE 180 160 90 100 88 77 80
89 d satyanarayana 19750 68 male 64 laterjet procredure-rec shoulder dislocation II DESFLURANE 200 180 120 140 93 89 80
90 s chandrashekar 19943 68 male 45 pcnl II DESFLURANE 120 100 90 120 98 79 90
91 g satyavathi 20165 69 female 52 rt modified radical mastectomy II DESFLURANE 140 120 100 120 98 89 89
92 h kalavathi 20178 70 female 42 subtotal thyroidectomy II DESFLURANE 100 90 80 100 98 78 98
93 a sivakumar 20321 72 male 73 laminectomy and discectomy II DESFLURANE 180 160 140 160 87 90 90
94 g bhagyalakshmi 11834 68 female 62 rt modified radical mastectomy III DESFLURANE 160 140 120 140 88 98 90
95 h jagannath 13285 67 male 45 clavicle plate fixation II DESFLURANE 200 180 90 120 88 80 90
96 k lakshmi kantham 18765 69 female 43 lt modified radical mastectomy II DESFLURANE 120 110 80 100 78 80 87
97 r krishna prasad 17659 66 male 62 proximal humerus plating II DESFLURANE 220 180 120 140 77 90 94
98 e suseela 18975 70 female 56 subtotal thyroidectomy II DESFLURANE 140 120 110 120 86 89 88
99 k leelavathi 20176 68 female 46 rt modified radical mastectomy II DESFLURANE 160 140 90 120 88 98 78
100 t laksmanarao 21128 68 male 52 laminectomy and discectomy III DESFLURANE 180 150 100 120 78 90 77
HR HR HR HR HR BASELINE SBP SBP SBP SBP SBP SBP SBP BASELINE DBP DBP DBP DBP DBP DBP DBP SPO2 SPO2 SPO2 SPO2 SPO2 SPO2 SPO2
(15min) (30min) (60min) (90min) (120min) (SBP) (5min) (10min) (15min) (30min) (60min) (90min) (120min) DBP (5min) (10min) (15min) (30min) (60min) (90min) (120min) Baseline (5min) (10min) (15min) (30min) (60min) (90min)
77 79 88 77 79 110 123 110 128 120 110 110 130 79 70 70 79 79 80 78 78 98 100 99 98 100 98 99
89 77 78 89 72 110 130 130 110 110 130 112 132 80 79 70 80 80 79 78 80 98 98 98 99 98 99 99
79 89 87 79 83 112 132 120 110 110 120 110 136 79 80 70 79 80 80 78 78 99 99 100 99 99 100 98
77 79 94 89 82 110 136 132 112 128 128 120 140 80 79 79 70 80 79 70 78 98 100 98 98 100 98 100
89 89 88 78 94 120 140 130 110 139 132 100 132 80 70 80 70 68 80 70 78 100 98 99 100 98 100 99
79 78 90 90 80 100 132 110 120 120 130 110 136 80 70 79 70 79 80 80 70 98 100 100 98 100 98 99
89 90 79 98 92 110 136 110 100 118 110 123 128 68 70 80 80 70 80 79 70 100 98 98 99 98 99 98
79 98 88 80 75 123 128 132 110 110 128 130 120 79 79 79 80 79 68 70 69 100 99 100 100 99 99 99
90 80 78 80 86 130 120 128 123 130 110 132 120 70 80 80 78 80 79 70 60 98 99 98 98 99 99 100
79 80 77 90 74 132 120 120 130 120 110 136 110 79 79 80 80 79 78 70 76 99 99 99 100 99 99 98
88 90 86 89 79 136 110 130 132 132 112 140 110 80 80 80 78 70 70 80 78 100 99 99 98 99 98 100
78 89 80 98 85 140 110 110 136 130 110 132 128 79 80 68 78 70 70 80 80 98 98 99 99 98 100 98
77 98 80 90 87 132 128 110 140 110 120 136 139 70 80 79 78 70 69 79 80 100 100 99 99 100 99 99
86 90 88 90 83 136 139 119 132 110 100 128 120 70 68 70 70 80 60 80 80 98 99 98 99 99 98 99
80 90 78 90 86 128 120 120 140 132 110 120 118 70 79 79 70 80 76 79 80 99 98 100 99 98 98 99
80 90 87 87 80 120 118 110 123 128 123 120 110 80 70 80 69 79 78 80 68 99 98 99 98 98 99 99
88 87 94 83 80 120 110 110 130 120 130 110 130 80 79 79 60 80 80 80 79 99 98 98 100 98 99 98
78 83 88 87 88 110 130 112 132 130 132 110 120 78 80 70 76 79 80 80 68 99 98 98 99 98 98 100
90 87 90 80 78 110 120 110 136 110 136 128 128 80 79 70 78 80 80 68 62 98 99 98 98 99 100 99
78 80 79 94 87 128 128 120 140 110 140 139 132 78 70 70 80 80 80 79 70 100 98 98 98 98 99 98
88 87 88 78 94 139 132 100 132 119 132 120 130 78 70 80 80 80 68 70 62 99 100 99 98 100 99 98
89 88 78 87 88 120 130 110 136 128 136 118 110 78 70 80 80 68 79 79 79 98 98 98 98 98 98 99
90 102 77 94 78 118 110 123 128 130 128 110 128 70 80 78 80 79 68 80 80 98 100 100 99 100 99 99
80 88 86 88 77 110 128 130 120 128 120 130 110 70 80 80 68 70 62 79 79 99 100 98 98 100 100 98
80 93 80 78 89 130 110 132 120 120 120 120 110 69 79 78 79 79 70 70 80 99 98 100 100 98 98 100
87 98 80 77 79 120 110 136 110 120 110 132 112 60 80 78 68 80 62 70 80 98 99 100 98 99 99 99
83 89 88 89 89 132 112 140 110 132 110 130 110 76 79 78 79 70 79 70 80 100 100 98 100 100 100 99
87 78 72 80 78 130 110 132 128 110 128 110 120 78 80 70 80 70 80 80 68 99 98 99 100 98 98 98
88 90 83 90 90 110 120 136 139 110 139 110 100 80 80 70 80 79 79 80 79 99 100 100 98 100 100 99
104 98 82 93 98 110 100 128 120 112 120 132 110 80 80 69 80 80 80 78 70 98 98 98 99 98 98 100
88 80 94 100 80 132 110 120 118 110 118 128 123 80 68 60 68 79 80 80 79 99 99 100 100 99 99 98
93 80 80 90 80 128 123 120 110 120 110 120 130 80 79 76 79 80 80 78 80 100 99 98 98 99 99 99
98 90 92 89 90 120 130 110 130 100 130 130 132 68 70 78 78 80 68 78 79 98 99 99 100 99 99 100
98 89 75 98 89 130 132 110 120 110 120 110 136 79 79 80 70 80 79 78 70 99 99 99 98 99 99 98
98 98 86 86 98 110 136 128 128 123 132 110 140 68 80 80 70 68 70 70 70 100 98 99 99 98 98 100
87 90 74 82 90 110 140 139 132 130 110 119 132 62 79 80 69 79 79 70 70 98 100 99 99 100 100 98
88 90 79 78 90 119 132 120 130 132 128 128 136 70 70 78 60 70 80 69 79 100 99 98 99 99 99 99
88 90 85 84 90 128 136 118 110 136 118 130 128 62 70 78 76 79 79 60 80 98 98 100 99 98 98 99
78 87 87 89 87 130 128 110 128 140 123 128 120 79 70 78 78 80 70 76 79 99 98 99 98 98 98 99
77 83 83 90 83 128 120 130 110 132 130 120 120 80 80 70 80 79 70 78 80 99 99 98 100 99 98 99
86 87 86 80 87 120 120 120 110 136 132 120 110 79 80 70 80 70 70 80 80 99 99 98 99 99 98 98
88 80 80 94 80 120 110 132 112 128 136 132 110 80 78 69 80 70 79 80 80 99 98 99 98 98 99 100
78 87 80 86 94 132 110 130 110 120 140 110 128 80 80 60 80 70 80 80 68 98 100 99 98 100 98 99
78 88 88 90 88 110 128 110 120 128 123 120 110 80 78 76 68 80 79 78 79 100 99 98 99 99 100 98
87 102 78 98 78 110 139 110 100 120 130 110 130 68 78 78 79 80 80 78 70 99 99 100 99 99 98 98
94 88 87 87 77 112 120 132 110 130 132 110 120 79 78 80 68 79 80 78 79 98 98 99 98 98 100 98
88 93 94 79 83 110 118 128 123 110 136 128 128 70 70 80 62 80 80 70 80 98 99 99 100 99 100 98
78 98 88 72 87 120 110 120 130 110 140 139 132 79 70 80 70 79 68 70 79 98 100 98 99 100 98 99
77 98 78 83 80 100 130 130 132 119 132 120 130 80 69 80 62 80 79 69 70 98 98 99 99 98 99 98
89 98 77 82 87 110 120 110 136 128 136 118 110 79 60 68 79 80 70 60 70 99 99 100 98 99 100 100
79 78 79 94 88 123 132 110 140 130 128 110 128 70 76 79 80 80 79 76 70 98 100 98 99 100 98 98
89 88 89 80 102 130 110 119 132 128 120 130 110 70 78 68 79 68 80 78 79 100 98 99 100 98 100 100
78 78 78 92 88 132 128 128 136 120 120 120 110 70 80 62 80 79 79 80 80 98 100 100 98 100 98 100
90 89 90 75 93 136 118 130 128 120 110 132 112 79 80 70 80 70 70 80 72 100 98 98 99 98 99 98
98 78 98 80 88 140 123 128 120 132 110 130 110 80 80 62 80 79 70 80 70 100 98 100 100 98 99 99
80 88 80 80 78 132 130 120 120 110 128 110 120 79 70 79 68 80 70 80 79 98 98 98 98 98 99 100
80 78 80 88 77 136 132 120 110 110 139 110 100 80 79 80 79 79 79 68 79 99 99 98 100 99 99 98
90 89 90 78 89 128 136 132 110 112 120 132 110 80 79 79 70 70 80 79 80 100 98 98 98 98 98 100
89 89 89 87 79 120 140 110 128 110 118 128 123 80 80 80 79 70 70 68 80 98 100 99 98 100 100 98
98 80 98 94 89 120 132 110 139 120 110 120 130 68 80 80 79 70 79 62 80 100 98 98 98 98 99 99
90 80 90 88 78 110 136 112 120 100 130 130 132 79 80 80 80 80 79 70 68 98 100 100 99 100 98 99
90 87 90 90 90 110 128 110 118 110 120 110 136 70 68 68 80 70 80 62 79 99 100 98 98 100 98 99
90 94 90 79 98 128 120 120 110 123 132 110 140 79 79 79 80 79 80 79 78 99 98 100 100 98 99 99
87 88 87 88 80 139 120 100 130 130 110 119 132 80 78 80 68 79 80 80 70 99 100 100 98 98 99 98
83 78 83 78 80 120 110 110 120 132 128 128 136 79 70 79 79 80 68 79 70 99 98 98 100 99 98 100
87 77 87 77 90 118 110 123 132 136 118 130 128 70 70 80 78 80 79 80 69 98 99 98 100 100 100 99
80 89 80 86 89 110 128 130 110 140 123 128 120 70 69 80 70 80 78 80 60 100 100 99 98 98 99 98
94 79 94 80 98 130 139 132 128 132 130 120 120 70 60 80 70 68 70 80 76 99 98 100 98 100 99 98
78 77 88 80 90 120 120 136 118 120 128 132 138 79 76 68 69 79 70 68 78 98 100 98 99 98 98 99
87 89 78 88 90 110 118 140 123 128 123 120 110 80 78 79 60 78 69 72 80 98 98 100 100 99 99 99
94 79 77 78 90 110 110 132 130 120 130 110 130 79 80 70 76 70 60 76 80 99 99 98 98 99 100 98
88 89 89 87 87 112 130 136 132 130 132 110 120 80 80 79 78 70 76 62 80 99 99 99 100 99 98 100
78 79 79 94 83 110 120 128 136 110 136 128 128 80 80 80 80 69 78 70 80 98 99 99 98 99 99 99
77 89 88 90 89 120 128 120 140 110 140 139 132 80 80 79 80 60 80 62 68 100 99 99 99 98 100 99
89 78 78 79 78 100 132 120 132 119 132 120 130 68 68 70 80 76 80 79 79 99 98 99 99 100 98 98
79 90 87 88 90 110 130 110 136 128 136 118 110 79 62 70 80 78 80 80 80 99 100 98 99 99 100 99
89 98 94 78 98 123 110 110 128 130 128 110 128 70 70 70 68 80 80 79 79 98 99 100 99 98 98 100
78 80 88 77 80 130 128 128 120 128 120 130 110 79 62 80 79 80 68 80 70 99 98 99 98 98 98 98
90 80 90 86 80 132 110 139 120 120 120 120 110 80 79 80 68 80 62 80 70 100 98 98 100 99 98 99
98 90 79 80 90 136 110 120 110 120 110 132 112 79 80 79 62 80 70 80 70 98 98 98 99 99 99 100
80 89 88 80 89 140 112 118 110 132 110 130 110 70 79 80 70 68 62 68 79 99 98 99 98 98 98 98
80 98 78 88 98 132 110 110 128 110 128 110 120 70 80 79 62 79 79 79 80 100 99 99 98 100 100 100
90 90 77 78 90 136 120 130 139 110 139 110 100 70 80 80 79 80 80 70 79 98 98 98 99 99 98 98
89 90 86 90 128 100 120 120 112 120 132 110 79 80 80 80 80 79 79 80 100 100 100 99 99 100 98
98 90 80 89 90 120 110 110 118 110 118 128 123 80 68 80 79 80 80 80 80 98 98 99 98 98 100 98
90 87 80 78 87 120 123 110 110 120 110 120 130 79 79 68 80 68 80 79 80 98 100 99 100 99 98 99
90 83 88 90 83 110 130 112 130 100 130 130 132 80 70 79 80 79 80 70 68 98 100 98 99 100 98 98
90 87 78 98 87 110 120 110 120 110 120 110 136 80 79 70 80 70 68 70 79 99 98 99 99 98 100 100
87 80 87 80 80 128 120 120 128 123 132 110 140 80 80 79 68 79 79 70 70 98 99 100 98 99 98 98
83 94 94 80 94 139 132 100 132 130 110 119 132 68 79 80 79 80 70 79 79 100 100 98 99 100 99 100
87 92 88 90 89 120 110 110 130 132 128 128 136 79 70 79 70 79 79 80 80 98 98 99 100 98 100 100
80 75 90 89 78 118 110 123 110 136 118 130 128 70 70 70 79 70 80 79 79 100 100 100 98 100 98 98
94 86 79 98 90 110 112 130 128 140 123 128 120 79 70 70 79 70 79 80 70 100 98 98 99 98 100 98
78 74 88 90 98 130 110 132 110 132 130 120 120 80 79 70 80 70 70 80 70 98 99 100 100 99 98 100
87 79 78 90 80 120 120 136 110 120 120 112 110 79 80 80 79 80 70 80 70 99 99 98 98 99 99 98
94 85 90 90 80 128 100 140 112 100 118 110 110 70 79 80 80 80 70 68 80 100 99 99 100 99 99 99
88 87 78 87 90 132 110 132 110 110 110 120 112 70 80 79 80 80 79 79 80 98 99 99 98 99 99 100
78 83 88 83 89 130 123 136 120 123 130 100 110 70 80 70 80 79 80 76 78 100 98 99 99 98 99 98
77 86 78 87 98 110 130 128 100 130 120 110 120 80 80 70 72 70 79 78 72 98 100 99 99 100 98 100
89 80 89 80 90 128 132 120 110 120 128 123 100 80 68 70 78 70 80 72 80 99 99 98 99 99 100 98
SPO2 RECOVERY INDICES SIDE EFFECTS POST OP ANALGESIA MMSC
MMSE SCORES
SCORES
(120min) EYE OPENING EXTUBATION COMMANDS ORIENTATION NO EFFECTS DIZZINESS HEADACHE NAUSEA VOMITING REQUIREMENT PREOP 1 HR 3HR 6HR
98 8 10 12 13 - NO 29 28 28 29
99 7 8 14 16 + YES 29 28 29 29
100 6 9 13 14 - NO 30 29 29 30
98 7 12 15 15 - NO 29 28 28 29
100 5 8 12 13 - NO 28 26 28 28
98 8 10 11 14 + YES 29 25 27 28
99 9 11 10 12 - NO 30 27 27 29
99 7 14 13 16 + NO 30 29 30 30
99 10 10 12 14 - NO 30 28 29 30
99 8 9 14 15 + YES 29 27 28 29
98 6 11 12 14 - NO 29 27 28 28
100 11 8 10 11 - YES 30 29 29 30
99 8 10 13 15 - NO 29 27 28 29
98 7 9 12 14 + NO 29 25 25 27
98 9 11 13 15 - YES 29 26 27 28
99 5 8 12 14 - NO 30 25 28 29
99 7 9 12 14 - YES 28 26 27 28
98 8 11 12 14 + NO 30 28 29 30
100 7 10 14 16 - NO 30 29 29 29
99 9 12 13 15 + YES 28 27 27 28
99 6 10 10 12 + YES 29 27 28 29
98 11 10 12 13 - NO 29 28 29 29
99 8 9 11 14 - NO 30 29 30 30
100 7 8 14 16 - NO 30 28 29 29
98 9 9 13 14 + YES 29 28 29 29
99 9 8 13 15 - NO 29 28 29 29
100 7 9 14 16 + YES 30 29 29 29
98 8 9 11 12 + NO 29 28 29 29
100 11 10 12 13 - NO 28 27 27 28
98 6 10 10 12 - NO 29 28 29 29
99 9 10 13 15 + YES 30 26 28 29
99 7 7 14 16 - NO 30 27 29 30
99 8 9 12 14 - NO 30 29 29 30
99 7 8 13 15 - YES 29 27 28 29
98 5 12 12 15 - NO 29 27 28 28
100 8 10 13 14 + YES 30 29 29 30
99 7 11 12 14 - NO 29 27 28 29
98 6 10 14 16 - NO 29 25 27 28
98 7 9 13 15 + YES 29 26 26 27
98 5 10 15 15 + NO 30 25 29 30
98 8 9 12 14 - NO 28 26 27 28
99 9 11 11 13 + NO 30 28 29 30
98 7 8 10 12 - NO 30 29 30 30
100 9 10 13 15 - NO 28 27 27 27
98 8 9 12 14 - NO 29 27 28 29
100 6 8 14 16 - NO 29 27 28 29
100 10 11 12 14 + YES 30 29 30 30
98 8 10 10 13 - NO 30 28 29 30
99 7 9 13 15 - YES 29 27 28 28
100 9 11 12 14 - NO 30 29 30 30
98 5 7 8 9 - NO 29 28 28 29
100 4 6 7 9 - NO 29 26 28 30
98 4 6 8 10 + YES 30 28 29 30
99 5 7 9 12 - NO 30 29 30 27
99 5 7 8 10 - NO 27 24 26 29
99 6 8 10 13 - YES 30 26 27 29
99 4 6 8 11 - NO 29 27 28 30
98 4 6 8 10 - NO 30 27 29 27
100 4 6 9 11 + YES 28 24 25 30
99 4 6 8 10 - NO 30 29 29 30
98 5 7 9 12 + NO 30 28 29 30
98 5 7 10 13 - NO 30 27 29 28
99 5 8 10 12 - NO 28 27 28 28
99 5 7 9 11 + YES 29 25 27 30
98 5 7 9 10 - NO 30 29 30 28
100 4 6 8 10 - NO 28 27 27 30
99 4 6 8 11 - NO 30 27 29 30
99 4 6 9 12 + YES 30 29 30 27
98 4 6 8 10 - NO 28 24 26 30
99 6 8 11 13 + NO 30 29 30 29
100 4 6 8 10 - YES 29 27 28 28
98 5 7 9 12 - NO 28 25 27 30
99 4 6 8 10 - NO 30 29 30 29
100 4 6 8 11 + NO 29 27 28 30
98 5 7 9 12 - NO 30 27 29 29
100 5 8 10 12 + YES 29 29 29 29
98 5 7 9 11 - NO 29 26 28 30
98 5 7 9 11 - YES 30 28 29 30
98 4 6 8 10 + NO 30 29 30 26
99 4 6 8 10 - YES 27 23 24 30
98 4 5 7 9 + NO 30 29 29 29
100 4 6 8 11 - NO 29 27 28 29
98 5 7 9 12 - YES 30 27 28 30
100 5 7 10 11 + NO 28 27 27 29
100 5 8 11 13 - NO 30 26 28 30
98 6 9 11 12 - NO 30 29 29 30
98 4 6 8 10 - YES 30 29 30 28
100 5 7 9 11 - NO 28 25 27 29
98 4 7 10 12 - NO 29 27 28 29
99 5 6 8 9 - NO 30 26 27 28
100 5 7 9 10 + YES 28 28 28 30
98 4 6 8 10 - NO 30 27 29 30
100 4 6 8 11 - NO 30 27 29 28
98 4 7 10 12 + YES 28 27 28 30
99 4 6 9 10 - NO 30 28 29 29
99 5 7 10 12 + YES 29 25 28 28
99 5 8 10 11 - NO 28 25 27 30
99 5 7 9 11 + NO 30 28 29 29
98 4 6 8 11 - NO 29 29 29 30
100 5 8 9 12 - YES 30 27 29 30

Sevoflurane Vs Desflurane Evaluation of Cognitive Functions in Elderly Patients Undergoing Surgeries

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Sevoflurane Vs Desflurane Evaluation of Cognitive Functions in Elderly Patients Undergoing Surgeries

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Dissertation on

“TO COMPARE THE COGNITIVE FUNCTION AND RECOVERY

A Dissertation Submitted to the

Dr. N.T.R UNIVERSITY OF HEALTH SCIENCES,

Dr. ARASAVALLI SIVANWESH, M.B.B.S.

Under the direction and guidance of

Dr. T. PREM SAGAR, M.D.

Kakinada Dr.T. PREM SAGAR, M.D

Dr. B.SOWBHAGYA LAKSHMI, M.D.

I Dr.ARASAVALLI SIVANWESH here by declare that this dissertation thesis entitled

“TO COMPARE THE COGNITIVE FUNCTION AND RECOVERY

CHARACTERISTICS AFTER DESFLURANE VERSUS SEVOFLURANE

ANAESTHESIA IN ELDERLY PEOPLE POSTED FOR VARIOUS SURGICAL

PROCEDURES UNDER GENERAL ANAESTHESIA – A Prospective,

SAGAR, M.D, Professor, Department Of Anaesthesiology, Rangaraya Medical

Anaesthesiology by Dr. N.T.R University of Health Sciences , Vijayawada and the

examination to be held in 2019.

This study was conducted at Government General Hospital, Kakinada. I

Dr. ARASAVALLI SIVANWESH

Rangaraya Medical College

It is with an overwhelming sense of gratitude and respect that I

I owe my heartfelt gratitude and utmost respect to Dr. B. SOWBHAGYA

I am very grateful to Dr. K.VIJAYENDRA KUMAR BABU, M.D.,

I sincerely thank Dr.A.VISHNU VARDHAN, M.D., Professor,

I am extremely thankful to Dr.P. KRISHNA PRASAD, M.D., Associate

I am greatly indebted to my Co-guide Dr. B. VISHNU MAHESH BABU,

I am thankful to Dr. PRASANNA KUMAR, M.D., Associate Professor,

I express my thanks to all my Assistant Professors, Dr. Y. ATCHYUTHA

I am thankful to Dr. MAHA LAKSHMI, M.S., Principal, Rangaraya Medical

2. AIM OF THE STUDY ................................................................................................. 3

3. UPTAKE AND DISTRIBUTION OF INHALATIONAL ANESTHETICS........ 4

4. THEORIES OF ANESTHETIC ACTION ................................................................. 8

6. TEC 6 VAPORIZER ................................................................................................... 12

7. INHALED ANESTHETICS AND COGNITIVE PERFORMANCE .................... 17

8. REVIEW OF LITERATURE .................................................................................... 19

:HISTORY : INCIDENCE AND. RISK FACTORS FOR POCD

:STUDIES COMPARING SEVOFLURANE AND DESFLURANE

9. MATERIALS AND METHODS ................................................................................ 38

10. STATISTICAL ANALYSIS ...................................................................................... 42

11. OBSERVATION AND RESULTS......................................................................... 43

13. CONCLUSION ........................................................................................................... 65

14. SUMMARY ................................................................................................................. 66

15. BIBLIOGRAPHY ........................................................................................................67

16. ANNEXURES ............................................................................................................. 75

Table 1: Partition coefficients of volatile anesthetics ...................................................... 6

graph 1: Distribution of mean age in years among treatment groups…....................... 43

Cognitive impairment (e.g. confusion, delirium) is a significant problem in elderly

patients during the early postoperative period 1, 2,3,4.

associated with further complications like decubitus ulcers, pneumonia or thrombosis.

function, despite a successful surgical procedure.5 Alarmingly, patients experiencing POCD

are at a cumulative risk of death in the first year after surgeries.

depending on the type of operation5.

decline after noncardiac operations has not so well studied.

number of patients having a cognitive impairment.

facilitating a faster recovery from general anesthesia.

emergence from anaesthesia.

vs 48) coefficients of desflurane versus sevoflurane, respectively6.

body and also provide for shorter emergence times.

1. To compare the speed of recovery in elderly patients undergoing

general anesthesia with sevoflurane or desflurane.

2. To determine the incidence and duration of cognitive impairment in

elderly patients undergoing general anesthesia with a sevoflurane or

effect depends on attainment of a therapeutic tissue level in the CNS.