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Low Flow Anaesthesia

Dr.J.Edward Johnson.M.D.(Anaes),D.C.H.
Asst.Professor,
Kanyakumari Govt. Medical College Hospital.

INTRODUCTION:

As early as in 1850 John Snow recognized that a considerable amount of inhalation anaesthetics
were exhaled unchanged in the expired air of anaesthetized patients which could be reinhaled to
prolong the effect of narcotics. (1) In 1924, Ralph Waters introduced to-and-fro canister
rebreathing systems equipped with carbon dioxide absorbers (2) while Brian Sword used the
circle system, which utilized sodalime for absorption of CO2.

In 1954 halothane was introduced, a new volatile anaesthetic characterized by high anaesthetic
potency with narrow therapeutical width. The vapourisers used for halothane at that time needed
high flow rate for estimation of vapour concentration and it didn´t work sufficiently reliably and
precisely in the low flow range. So, it became clinical routine to use fresh gas flows as high as 4
to 6 l/min, completely excluding any significant rebreathing. (3) However the development of
modern anaesthetic apparatus, the availability of comprehensive gas monitoring, an increasing
environmental awareness, the introduction of new advantageous but expensive inhalational
anaesthetics, have helped in the rediscovery of low flow anaesthesia.

DEFINITION:

Low flow anaesthesia has various definitions. Any technique that utilises a fresh gas flow (FGF)
that is less than the alveolar ventilation can be classified as “Low flow anaesthesia”.

Baker (4) has suggested the following modification of Simionescu's (5) classification of flow
rates of gases into anaesthetic circuits:

Metabolic flow -250 ml /min

Minimal flow 250-500 ml/min

Low flow 500-1000 ml/min

Medium flow 1-2 l/min

High flow 2-4 l/min

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Very high flow >4 l/min

While metabolic flow conditions can only be achieved with the injection of liquid anaesthetic
into the circle circuit, it is possible to approximate this using pharmacokinetic knowledge of drug
uptake. Metabolic flow is oxygen alone, while the other flows consist of metabolic oxygen with
varying amounts of extra oxygen, nitrous oxide or air. (6)

The general term - low flow anaesthesia - should be restricted to defining an anaesthetic
technique in which a semiclosed rebreathing system is used recirculating at least 50% of the
exhaled air back to the patient after CO2 absorption. Using modern rebreathing systems this will
be achieved only if the fresh gas flow is reduced to at least 2 l/min. (7)

LOW FLOW ANAESTHESIA - THE THEORY:

Rebreathing systems can be used in different ways: If used with a fresh gas flow equal to the
minute volume of the patient, the share of rebreathing will be negligible. Nearly completely the
expired air will vented out off the system as excess gas via the APL-valve. The patient gets
nearly pure fresh gas. If a flow of 4.0 l/min is used, the share of rebreathing will increase to
about 20%. The patient inhales a gas the composition of which still resembling that of the fresh
gas. Only if the flow is reduced to at least 2.0 l/min or lower values, the share of rebreathing will
reach 50% or more. Thus, only when low fresh gas flows are used the share of rebreathing will
become significant, and judicious use is made from the rebreathing technique. (8)

Category High flow Inter Low flow Minimal Closed

5L/Min Mediate 1 l/min Flow circuit
2.5 l/min 0.5 l/min 0.3 – 0.5
l/min
Percentage 0% 52% 86% 97% 100%
rebreathing
For an average 70kg patient with a minute ventilation of 4.8 l/min

The strategy of minimal flow anaesthesia is to add to the circuit only the amount of anaesthetic
taken up by the patient, thus reducing waste.

A minimum of 250ml/min of oxygen is needed to meet the basic metabolic requirements of a

normothermic, awake patient at rest. So the delivery of at least this amount of oxygen per minute
will be safe in an anaesthetised patient. This replacement will be constant provided the metabolic
rate remains constant.

Brody Formula for Oxygen Uptake: ​V​O2​ = 10 x KG [kg] 3/4​

​ [mL/min]​ (9)

Nitrous oxide uptake of a normal body weight adult patient can be roughly estimated by applying
Severinghaus´ formula (10)
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​V​N2O​ = 1000 t​-1/2​ [mL/min]

Having 70% in N​2​O, with a BW of 70 kg.

That gives a – 1​st​ minute uptake of 1000mL

- 200 mL/min uptake after 25 minutes

- 140 mL/min uptake after 50 minutes

- 90 mL/min uptake after 2 hours (120 minutes)

Volatiles - Usually delivered from a vaporiser out of circuit, are needed to replace metabolized
and absorbed volatile agent and gas vented to the atmosphere. A variable replacement is needed
as it depends on the solubility and amount of agent metabolized.

Independent of the inhalational anaesthetic agents employed uptake can be calculated using
Lowe’s formula (11):

V​AN​ = f x MAC x ​λ​B/G​ x Q x t​-1/2​

f = factor that defines the inhalation concentration that is sufficient for unresponsive skin incision
at ~MAC ​1.3

λ​B/G​ = blood/gas partition coefficient

Q = cardiac output

t = time

Thus, assuming a constant gas composition circulating within the breathing system, the total gas
uptake will be the sum of oxygen, nitrous oxide and inhalational anaesthetic uptake, is following
a power function. Initially it is high and declines sharply during the first 30 minutes .
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Reproduced from “Low Flow Anesthesia with Draeger machines” by Prof.J.A.Baum.

LOW FLOW ANAESTHESIA - THE PRACTICE

Equipment needed to conduct Low flow anesthesia:

Anaesthetic apparatus:

The technical features of the anaesthetic apparatus have to comply with following requirements
(7, 8);

The fresh gas controls should work precisely, and the flow meter tubes should be
calibrated and graduated in the low flow range. Newer anaesthetic machines may be also
equipped with electronic fresh gas flow displays, allowing the setting of very low flows.
The vaporisers should feature pressure, temperature and flow compensated.
The leakage rate of the rebreathing systems must not exceed 100 mL/min.
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There should be fresh gas flow compensation for anaesthetic ventilator in the anaesthesia
machine. Newer generation anaesthetic machines feature fresh gas flow compensation ie
the preset tidal volume is being delivered to the patient independently of the fresh gas
flow rate or its variation.
The performance of low flow techniques is significantly facilitated by the availability of
an anaesthetic gas reservoir, by which small accidental gas volume deficiencies can be
balanced. . Such gas reservoir can be, alternatively, the endinspiratory volume contained
in Manual bag (fresh gas decoupling valve), Floating bellows (bellows-in-box
ventilators) or Reservoir bag (bag-in-bottle ventilators).

Essential Monitors:

Monitoring for Safe Performance of Low Flow Anaesthesia needs continuous measurement of
(12)

Inspiratory oxygen concentration (because of Increased rebreathing volume)

Airway pressure and/or minute volume (because of Less excess gas added to the circuit)

Anaesthetic agent concentration in the circuit (because of Difference of gas composition

Fresh gas versus gas in the circuit)
Expiratory CO​2​-concentration (because of Exhaustion of the absorbent)

HOW TO PERFORM LOW FLOW ANAESTHESIA:

INDUCTION:

Premedication can take place in accordance with every routinely used scheme. There are no
procedure specific requirements for premedication and induction.

Induction if performed using low flows would take an unacceptably long time. If induction is
performed with an intravenous agent it may take very long time to achieve the desired alveolar
concentrations.

Methods to achieve desired gas and agent concentration in short time:

1. Use high flows for a short time

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2. Use Prefilled circuit

3. Use large doses of anaesthetic agents

4. Injection techniques

1. Use of high flows for a short time

During an initial phase, lasting 10 to 20 minutes, a comparatively high fresh gas flow of about 4
L/min is set at the anaesthetic machine (for example 1.4 L/min O2 and 3.0 L/min N2O).

The following settings of the vaporizers are used routinely during the initial phase:

Halothane to 1.0 - 1.5 vol%,

Enflurane to 2.0 - 2.5 vol%,
Isoflurane to 1.0 - 1.5 vol%,
Sevoflurane to2.0 – 2.5 vol%, and
Desflurane to 4.0 – 6.0 vol%.

If these settings are used over the first 10 to 15 minutes an expiratory concentration will be
achieved corresponding to about 0.8 x MAC of the respective anaesthetic agent​. ​In addition to a
nitrous oxide MAC of about 0.6, corresponding to a nitrous oxide concentration of 60%, this will
result in a common MAC of 1.3 representing the AD95, the anaesthetic gas concentration
guaranteeing a sufficient anaesthetic depth for 95% of all patients to tolerate the skin incision
without any movement.

During this initial high flow phase the desired anaesthetic gas composition must be established
within the entire gas containing system, an adequate depth of anaesthesia must be reached, and
denitrogenation must be completed. (8,12)

Low Flow Anaesthesia the initial phase should last about 10 minutes, in Minimal Flow
Anaesthesia about 15 minutes, but for very strong patients it may be even as long as
20 minutes.

2. Prefilled circuit
The second method is utilising a different circuit like Magills for preoxygenation.
Simultaneously, the circle is fitted with a test lung and the entire circuit is filled with the gas
mixture of the desired concentration. Following intubation, the patient is connected to the circuit
thereby ensuring rapid achievement of the desired concentration in the circuit.

3. Use of large doses of anaesthetic agents

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The third method consists of adding large amounts of anaesthetic agent into the circuit so that the
circuit volume + FRC rapidly achieves the desired concentration as well as compensates for the
initial large anaesthetic gas uptake.

The usual requirement of anaesthetic agent is approximately 400 - 500 ml of vapour in the first
10 minutes which implies an average need of 40 - 50 ml of vapour per minute during the first 10
minutes. Most of the vaporisers allow a maximal concentration of 5% to be delivered. At a
setting 5% in the vaporiser, with a FGF of one litre/minute, the required mass of 500 ml of
vapour could be added to the circuit so that the alveolar concentration could be built up.

4. Injection techniques

Fig. 1

An alternative method for administering the large amounts of the agents is by directly injecting
the agent into the circuit, a form of VIC. (13-18) This is an old, time-tested method and is
extremely reliable. Each ml of the liquid halothane, on vaporisation yields 226 ml of vapour and
each ml of liquid isoflurane yields 196 ml of vapour at 20​o​C. Hence, the requirement of about
2ml of the agent is injected in small increments into the circuit. The high volatility coupled with
the high temperature in the circle results in instantaneous vaporisation of the agent. The injection
is made through a self sealing rubber diaphragm covering one limb of a metal t piece or a
sampling port, inserted into either the inspiratory or the expiratory limb (fig. 1).
The intermittent injections are often made in 0.2-0.5 ml aliquots manually. Doses should never
exceed 1ml at a time.

The exact dose to be used is calculated thus:

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Priming dose (ml vapour) = Desired concentration x {( FRC + Circuit volume) +

(Cardiac output x BG Coeff.)}

The Cardiac output and the FRC can be estimated for the patient based on standard nomograms.
This priming dose is the dose required to bring the circuit volume + FRC to the desired
concentration and is injected over the first few minutes of the closed circuit anaesthesia. Besides
this, an amount of agent necessary to compensate for the uptake of the body must also be added
and this is calculated depending on the uptake model being used (vide infra).(19)

Flow reduction:

If Low Flow Anaesthesia is to be performed, the fresh gas flow can be reduced to 1.0 l/min after
10 minutes. Flow reduction will lead to a significant increase of rebreathing. The inspired gas,
thus, contains a markedly increased proportion of the exhaled gas which already had passed the
patient´s lung and contains less oxygen. The resulting decrease of oxygen content in the gas
mixture has to be compensated by increasing the fresh gas oxygen content. Thus, to maintain a
safe inspired oxygen concentration of about 30 % in Low Flow Anaesthesia, the fresh gas
oxygen concentration has to be increased to 50%, but at least to 40%.

With the fresh gas flow reduction, furthermore, the amount of anaesthetic vapour delivered into
the system is markedly reduced. This has to be compensated by a corresponding significant
increase of the agent´s concentration in the fresh gas. (8,12)

Inspired oxygen and nitrous oxide concentration:

The continuous change in inspiratory oxygen concentration during the course of anaesthesia is
due to the continuous decrease of the nitrous oxide uptake.

To maintain safe inspiratory oxygen concentration the following steps must be taken:

The oxygen concentration of the fresh gas must be adequately increased when the flow
rate is reduced (Low Flow Anaesthesia: 40-50 vol.% O2, Minimal Flow Anaesthesia:
50-60 vol.% O2).

The inspiratory oxygen concentration must be monitored continuously, and the lower
alarm limit set to the nominal inspiratory value. This nominal value is 30 vol.%, in
accordance with the recommendations of Barton and Nunn. ( 20,21)
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If the inspiratory O2-concentration falls below 30 vol %, the O2-flow must be increased
by l0% of the total gas flow, and the N2O-flow be reduced by the same value. Thus,
during Low Flow Anaesthesia the O2-flow must be increased by 100 mL/min and by 50
mL/min during Minimal Flow Anaesthesia each time that the alarm limit is reached. The
nitrous oxide flow must be reduced accordingly. (8,12)

Concentration of inhalational anaesthetics:

When the flow is being reduced the setting on the vaporizer must be increased. This is the only
way that the desired concentration of anaesthetic agent can be maintained in the breathing system
after flow reduction.
Using a FGF of 5 LPM and a vaporizer setting of 1%, we give to the patient:
5000mL/min x 0.01 = 50 mL/min
What would be the vaporizer setting if we would use a FGF of 1 LPM for the same 50 mL to be
delivered?
1000mL/min X ? = 50 mL/min
​? = 0.05

That means that the vaporizer should be opened to 5%.

Expiratory Halothane concentration (nominal value, 0.6 vol.% ≈ 0.8 MAC, patient 75 kg)
and Vaporiser settings ​(12)

For fresh gas flow of 2lts/min

10-15 min After 10 min After 20min

Flow 4.5 L/min Flow 2.0 L/min Flow 2.0 L/min
Concent 1.3 Vol% Concent 1.5 Vol% Concent 1.0 Vol%

For fresh gas flow of 1lt/min (Low Flow)

10-15 min After 10 min After 30min

Flow 4.5 L/min Flow 1.0 L/min Flow 1.0 L/min
Concent 1.3 Vol% Concent 2 Vol% Concent 1.5 Vol%

For fresh gas flow of 0.5 lt/min (Minimal Flow)

10-15 min After 10 min After 30min After 45min

Flow 4.5 L/min Flow 0.5 L/min Flow 0.5 L/min Flow 0.5 L/min
Concent 1.3 Vol% Concent 3 Vol% Concent 2.5 Vol% Concent 2.0 Vol%
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​ Expiratory Isoflurane concentration (nominal value, 0.9 vol.% ≈ 0.8 MAC, patient
75 kg) and Vaporiser settings ​(12)

For fresh gas flow of 2lts/min

10 min After 10 min After 30min

Flow 4.5 L/min Flow 2.0 L/min Flow 2.0 L/min
Concent 1.5 Vol% Concent 1.5 Vol% Concent 1.3 Vol%

For fresh gas flow of 1lt/min (Low Flow)

10 min After 10 min After 30min

Flow 4.5 L/min Flow 1.0 L/min Flow 1.0 L/min
Concent 1.5 Vol% Concent 2 Vol% Concent 1.5 Vol%

For fresh gas flow of 0.5 lt/min (Minimal Flow)

10 min After 10 min

Flow 4.5 L/min Flow 0.5 L/min
Concent 1.5 Vol% Concent 2.5 Vol%

Expiratory Sevoflurane concentration (nominal value, 1.7 vol% ≈ 0.8 MAC, patient 75kg)
and Vaporiser settings ​(12)

For fresh gas flow of 2lts/min

10-15 min After 10 min

Flow 4.5 L/min Flow 2.0 L/min
Concent 2.5 Vol% Concent 2.0 Vol%

For fresh gas flow of 1lt/min (Low Flow)

10-15 min After 10 min After 20min

Flow 4.5 L/min Flow 1.0 L/min Flow 1.0 L/min
Concent 2.5 Vol% Concent 2.5 Vol% Concent 2.0 Vol%

For fresh gas flow of 0.5 lt/min (Minimal Flow)

10-15 min After 10 min After 30min

Flow 4.5 L/min Flow 0.5 L/min Flow 0.5 L/min
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Concent 2.5 Vol% Concent 3.0 Vol% Concent 2.5 Vol%

Note: Actually the American FDA and the manufacturer likewise still recommend not to use
sevoflurane with fresh gas flows lower than 1.0 L/min, and in low flow technique the
sevoflurane load shall not exceed 2 MACh. According to recently published data, any restriction
with respect to the fresh gas flow used in sevoflurane anaesthesia seems not to be justified any
more. (12)

Expiratory Desflurane concentration (nominal value 3.5%, patient 75 kg) and Vaporiser
settings

For fresh gas flow of 1lt/min (Low Flow)

10min After 10 min

Flow 4.5 L/min Flow 1.0 L/min
Concent 4.0 Vol% Concent 4.0 Vol%

For fresh gas flow of 0.5 lt/min (Minimal Flow)

10min After 10 min

Flow 4.5 L/min Flow 0.5 L/min
Concent 4.0 Vol% Concent 5.0 Vol%
Time constant:

The time required for flow through a container to equal the capacity of the container.

Time constant = volume (capacity)/flow

Time Constant % washin/washout
1 63%
2 86%
3 95%
4 98%
For example;
If 10 liter box is initially filled with oxygen and 5 l/min of nitrogen flow into box then, the
TC is volume (capacity)/flow.
TC = 10 / 5 = 2 minutes.
So, the nitrogen concentration at end of 2 minutes is 63%.(22)

The time constant is a measure for the time required for changes in the composition of the fresh
gas to lead to corresponding changes in the composition of the gas in the anaesthetic system.
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Based on the calculation formula given by Conway (23)

​T = V​S​ / (V​D​ - V​U​)
the time constant T is proportional to the volume of the system (ventilator and lung volume) V​S
and inversely proportional to the difference between the amount of anaesthetic agent delivered
into the breathing sytem V​D​ and the individual uptake V​U​ at the same time.

To increase the depth of anaesthesia concentration of the anaesthetic agent, the flow must be
increased for a short time. By this manoevre the desired higher agent concentration can be
established rapidly within the breathing system (​anaesthesia with short time constant)​

On the other hand the anaesthetist also can make use of the long time constant with the low fresh
gas flow is maintained and a concentration dialed at the vaporiser significantly exceeding the
newly desired nominal concentration. (​anaesthesia with long time constant)​ (12)

Whenever the gas composition within the breathing system needs to be changed rapidly, the
fresh gas flow has to be increased for adequately accelerating the wash in of the newly aspired
gas composition. If low flow anaesthesia is performed with the newer volatiles, characterized by
low anaesthetic potency and solubility like sevoflurane and desflurane, the time constants will be
significantly shorter as V​D​ can be raised considerably and V​U​ is extremely low. (24-27)

Recovery phase:

According to the long time constant, the vaporizer can be closed about 15 to 20 minutes before
the definite end of the surgical procedure. If the low flow is maintained, the decrease of the
anaesthetic's concentration is delayed and slow. During that time recovery of spontaneous
breathing can be induced by using the SIMV ventilation mode or by manual assistance of the
ventilation. Not until about five minutes before extubation the anaesthetic gases are washed out
by switching to high flow of pure oxygen.

In another method activated charcoal is used. (28) Activated charcoal when heated to 220​o​C
adsorbs the potent vapours almost completely. Hence, a charcoal-containing canister with a
bypass is placed in the circuit. Towards the end of the anaesthesia, the gas is directed through the
activated charcoal canister. This results in the activated charcoal adsorbing the anaesthetic agent
resulting in rapid recovery and at the same time, reducing theatre pollution. (19)

​Advantages of low flow anaesthesia:

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1. Quality of patient care:

Tracheal intubation bypasses the upper airways, thus, eliminating the main effect of the inhaled
gases ie warming and humidification. In the spontaneously breathing patient the isothermic
saturation boundary of the inspiratory mixture (the point where the gases reach 37​0​C and 100%
humidity) is located at the 4-5th generation of bronchi. (29,30)

After tracheal intubation, as a consequence of the upper airway bypass, this isothermic point is
shifted down about 10cm in a bronchial region not suited to deal with dry and cold gases and not
suited to physiologically condition the respiratory mixture.

Using high FGF Anesthetic gases are usually delivered dry and cold. Reducing FGF makes gases
recirculating in the circle system more humid and warmer. With low FGF the gases repeatedly
circulate through the CO​2​ absorber, consequently more heat and humidity is produced through
the chemical CO​2​ absorption process.

Breathing warm and humid gases is beneficial for the patient because they help maintaining body
heat, prevent postoperative shivering and airway and bronchial drying during ETT use.

2. Economic benefits:

Over 80% of anesthetic gases are wasted when flows of 5 L/min are used. Several studies also
prove that the use of low and minimal flow anesthesia techniques can dramatically reduce the
(annual) costs of volatile anesthetics. (31-33) Typically the reduction of FGF from 3 L/min to 1
L/min results in savings of about 50% of the total consumption of any volatile agent.

3. Environmental benefits

Both, nitrous oxide and the volatile anaesthetics contribute to the destruction of the ozone layer
and to the greenhouse effect. The ozone destructive potential of the volatile anaesthetics
halothane, enflurane and isoflurane, which are partially halogenated chlorofluorocarbons (CFCs),
is assumed to be only 0.1-1 % of all fully substituted CFCs. Furthermore, the proportion of
nitrous oxide, emitted from hospitals, is only about 1 % of the total amount of nitrous oxide
polluting the atmosphere.

The consistent use of rebreathing systems alone with the nitrous oxide flow reduced to 0.5 L/min
(Low Flow Anaesthesia) or even 0.2 L/min (Minimal Flow Anaesthesia) can reduce the
concentration of nitrous oxide at the workplace to 29 or 15 ppm respectively.
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Anaesthetists are morally obliged to minimize pollution in an age of increasing environmental

awareness, and it is their duty to use all technical facilities available to achieve this. (34-38)

Disadvantages of LFA:

Low flow anaesthetic techniques are not suitable for the following procedures: (12)

● Short term anaesthesia with a face mask

● Procedures with imperfectly gas-tight airways (i.e. bronchoscopies with a rigid
bronchoscope)
● Use of technically unsatisfactory equipment with a high gas leakage
● Inadequate monitoring (i.e. malfunction of the oxygen measuring device).

Trace gas accumulation:

During low flow anaesthesia the following gases of low solubility may accumulate within the
breathing system: nitrogen, methane, argon (if oxygen concentrators are used as the source for
medical oxygen) and hydrogen. (39,40)

Although the accumulation of these gases is not harmful for the patients anyway, these low
soluble gases can be washed out of the breathing system by intermittent flushing phases using a
flow rate of 5 L/min for 5 minutes.

All inhalational anaesthetics react with carbon dioxide absorbents by absorption and degradation,
most eagerly if the absorbent is desiccated (41). The new volatiles desflurane and sevoflurane are
more liable to react with the alkaline absorbents than the older anaesthetics halothane, enflurane
or isoflurane. Desflurane more than enflurane and isoflurane react with absolutely dry carbon
dioxide absorbents by generating carbon monoxide. Only partial wetting markedly reduces this
chemical reaction, and if soda lime contains only 4.8% and Baralyme only 9.5% water, carbon
monoxide generation is suppressed completely (42). Low flow anaesthesia, preserving the
moisture content of the absorbents, just can be taken as a measure preventing from carbon
monoxide generation. (43)

Sevoflurane more eagerly than halothane reacts with dry absorbents too (44,45). Both agents,
however, also react with normally wet carbon dioxide absorbents by generating haloalkenes:
Halothane by forming BCDFE = 1,bromo-1,chloro-2,2,difluoro-ethylene (46) and sevoflurane by
forming compound A = fluoromethyl-2,2,difluoro-1,trifluoromethyl-vinylether.
 15

Compound A concentration was found to increase with the extend of flow reduction, with the
absorbent´s temperature and the agent´s concentration (47,48). Some authors regard a compound
A load of 150 to 240 ppmh as potentially nephrotoxic in humans (49 - 51) and emphasize not to
use this anaesthetic with flows lower than 2.0 l/min. Contrarily, some authors estimate Low Flow
Anaesthesia with sevoflurane to be safe, arguing that mean peak concentrations in different
studies did not exceed 25 ppm and no signs of renal impairment were observed in any patient (52
- 54). Mazze recently published the results of an investigation on nephrotoxicity of compound A
in primates demonstrating that only at a load of at least 800 ppmh nephrotoxic effects occured
(55). Accepting this threshold for nephrotoxic load with compound A absolutely no flow
restriction would be justified. Even long lasting Minimal Flow Anaesthesia with sevoflurane
could be performed safely, although compound A peak concentrations were found to reach 50 to
60 ppm with this technique (56). Unlike in the United States, sevoflurane was approved for
clinical use without any fresh gas flow restriction in all countries of the European Common
Market.

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