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reasonable [0.05):< 0.05), unadjusted for multiple comparisons. Cardiovascular Surgery Desflurane was compared to isoflurane, sufentanil or fentanyl for the anesthetic management of coronary artery bypass graft (CABG), abdominal aortic aneurysm, peripheral vascular and carotid endarterectomy surgery in 7 studies at 15 centers involving a total of 558 patients. In all patients except the desflurane vs sufentanil study, the volatile anesthetics were supplemented with intravenous opioids, usually fentanyl. Blood pressure and heart rate were controlled by changes in concentration of the volatile anesthetics or opioids and cardiovascular drugs if necessary. Oxygen (100%) was the carrier gas in 253 of 277 desflurane cases (24 of 277 received N 2 O/O 2 ). CARDIOVASCULAR PATIENTS BY AGENT AND TYPE OF SURGERY 418 MALES, 140 FEMALES, AGES 27-87 (MEDIAN 64) Type of Surgery 13 Centers 1 Center 1 Center Isoflurane Desflurane Sufentanil Desflurane Fentanyl Desflurane CABG 58 57 100 100 25 25 Abd Aorta 29 25 - - - - Periph Vasc 24 24 - - - - Carotid Art 45 46 - - - - -- -- -- -- -- -- Total 156 152 100 100 25 25 No differences were found in cardiovascular outcome (death, myocardial infarction, ventricular tachycardia or fibrillation, heart failure) among desflurane and the other anesthetics. INDUCTION: Desflurane should not be used as the sole agent for anesthetic induction in patients with coronary artery disease or any patients where increases in heart rate or blood pressure are undesirable. In the desflurane vs sufentanil study, anesthetic induction with desflurane without opioids was associated with new transient ischemia in 14 patients vs 0 in the sufentanil group. In the desflurane group, mean heart rate, arterial pressure, and pulmonary blood pressure increased and stroke volume decreased in contrast to no change in the sufentanil group. Cardiovascular drugs were used frequently in both groups: especially esmolol in the desflurane group (56% vs 0%) and phenylephrine in the sufentanil group (43% vs 27%). When 10 µg/kg of fentanyl was used to supplement induction of anesthesia at one other center, continuous 2-lead ECG analysis showed a low incidence of myocardial ischemia and no difference between desflurane and isoflurane. If desflurane is to be used in patients with coronary artery disease, it should be used in combination with other medications for induction of anesthesia, preferably intravenous opioids and hypnotics. MAINTENANCE & RECOVERY: In studies where desflurane or isoflurane anesthesia was supplemented with fentanyl, there were no differences in hemodynamic variables or the incidence of myocardial ischemia in the patients anesthetized with desflurane compared to those anesthetized with isoflurane. During the precardiopulmonary bypass period, in the desflurane vs sufentanil study where the desflurane patients received no intravenous opioid, more desflurane patients required cardiovascular adjuvants to control hemodynamics than the sufentanil patients. During this period, the incidence of ischemia detected by ECG or echocardiography was not statistically different between desflurane (18 of 99) and sufentanil (9 of 98) groups. However, the duration and severity of ECG-detected myocardial ischemia was significantly less in the desflurane group. The incidence of myocardial ischemia after cardiopulmonary bypass and in the ICU did not differ between groups. Geriatric Surgery SUPRANE (desflurane, USP) plus N 2 O was compared to isoflurane plus N 2 O in a multicenter study (6 sites) of 203 ASA physical status II or III elderly patients, aged 57-91 years (median 71). INDUCTION: Most patients were premedicated with fentanyl (mean 2 µg/kg), preoxygenated, and received thiopental (mean 4.3 mg/kg IV) or thiamylal (mean 4 mg/kg IV) followed by succinylcholine (mean 1.4 mg/kg IV) for intubation. MAINTENANCE & RECOVERY: Heart rate and arterial blood pressure remained within 20% of preinduction baseline values during administration of SUPRANE (desflurane, USP) 0.5-7.7% (average 3.6%) with 50-60% N 2 O. Induction, maintenance, and recovery cardiovascular measurements did not differ from those during isoflurane/N 2 O administration nor did the postoperative incidence of nausea and vomiting differ. The most common cardiovascular adverse event was hypotension occurring in 8% of the SUPRANE patients and 6% of the isoflurane patients. Neurosurgery SUPRANE (desflurane, USP) was studied in 38 patients aged 26-76 years (median 48 years), ASA physical status II or III undergoing neurosurgical procedures for intracranial lesions. INDUCTION: Induction consisted of standard neuroanesthetic techniques including hyperventilation and thiopental. MAINTENANCE: No change in cerebrospinal fluid pressure (CSFP) was observed in 8 patients who had intracranial tumors when the dose of desflurane was 0.5 MAC in N 2 O 50%. In another study of 9 patients with intracranial tumors, 0.8 MAC desflurane/air/O 2 did not increase CSFP above postinduction baseline values. In a different study of 10 patients receiving 1.1 MAC desflurane/air/O 2 , CSFP increased 7 mm Hg (range 3-13 mm Hg increase, with final values of 11-26 mm Hg) above the predrug values. All volatile anesthetics may increase intracranial pressure in patients with intracranial space occupying lesions. In such patients, desflurane should be administered at 0.8 MAC or less, and in conjunction with a barbiturate induction and hyperventilation (hypocapnia) in the period before cranial decompression. Appropriate attention must be paid to maintain cerebral perfusion pressure. The use of a lower dose of desflurane and the administration of a barbiturate and mannitol would be predicted to lessen the effect of desflurane on CSFP. Under hypocapnic conditions (PaCO 2 27 mm Hg) desflurane 1 and 1.5 MAC did not increase cerebral blood flow (CBF) in 9 patients undergoing craniotomies. CBF reactivity to increasing PaCO 2 from 27 to 35 mm Hg was also maintained at 1.25 MAC desflurane/air/O 2 . Pediatric Surgery SUPRANE (desflurane, USP) or halothane with or without N 2 O was used to anesthetize 235 patients aged 2 weeks-12 years (median 2 years), ASA physical status I or II. INDUCTION: SUPRANE (desflurane, USP) is not recommended for induction of general anesthesia in infants or pediatric patients because of a high incidence of moderate to severe laryngospasm, coughing, breathholding, and secretions. The occurrence of oxyhemoglobin desaturation was 26%. For incidence, see ADVERSE REACTIONS . MAINTENANCE & RECOVERY: The concentration of SUPRANE (desflurane, USP) required for maintenance of general anesthesia is age-dependent (see INDIVIDUALIZATION OF DOSE ). Changes in blood pressure during maintenance of and recovery from anesthesia with desflurane/N 2 O/O 2 are similar to those observed with halothane/N 2 O/O 2 . Heart rate during maintenance of anesthesia is approximately 10 beats per minute faster with desflurane than with halothane. Patients were judged fit for discharge from post-anesthesia care units within one hour with both desflurane and halothane. There were no differences in the incidence of nausea and vomiting between patients receiving desflurane or halothane. INDIVIDUALIZATION OF DOSE (Also see DOSAGE AND ADMINISTRATION ) Preanesthetic Medication: Issues such as whether or not to premedicate and the choice of premedicant(s) must be individualized. In clinical studies, patients scheduled to be anesthetized with desflurane frequently received IV pre-anesthetic medication, such as opioid and/or benzodiazepine. INDUCTION: In adults, some premedicated with opioid, a frequent starting concentration was 3% desflurane, increased in 0.5-1.0% increments every 2 to 3 breaths. End-tidal concentrations of 4-11% SUPRANE (desflurane, USP) with and without N 2 O, produced anesthesia within 2 to 4 minutes. When desflurane was tested as the primary anesthetic induction agent, the incidence of upper airway irritation (apnea, breathholding, laryngospasm, coughing and secretions) was high (see ADVERSE REACTIONS ). During induction in adults, the overall incidence of oxyhemoglobin desaturation (SpO 2] FDA Consumer Updates Depression: FDA-Approved Medications May Help Dealing with ADHD: What You Need to Know Making Decisions for Your Health: Getting the Info You Need FDA: Cutting-Edge Technology Sheds Light on Antibiotic Resistance More FDA updates a delegated


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