In this episode, Dr. Ross Kennedy and Dr. Cas Woinarski join us to discuss the evidence on whether low-flow anesthesia with sevoflurane is safe. We discuss Compound A generation and nephrotoxicity. This episode was made possible through production and research support from Davies Agyekum, MD, PhD.  Thanks for listening! If you enjoy our content, consider helping us offset the costs of production by donating through our Patreon at <a href= "https://bit.ly/3n0sklh">https://bit.ly/3n0sklh</a>. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast updates and new literature updates. Email us at <a href= "mailto:depthofanesthesia@gmail.com">depthofanesthesia@gmail.com</a>. Music by Stephen Campbell, MD. — References Ebert TJ, Frink EJ Jr, Kharasch ED. Absence of biochemical evidence for renal and hepatic dysfunction after 8 hours of 1.25 minimum alveolar concentration sevoflurane anesthesia in volunteers. Anesthesiology. 1998 Mar;88(3):601-10. doi: 10.1097/00000542-199803000-00008. PMID: 9523801. Ebert TJ, Messana LD, Uhrich TD, Staacke TS. Absence of renal and hepatic toxicity after four hours of 1.25 minimum alveolar anesthetic concentration sevoflurane anesthesia in volunteers. Anesth Analg. 1998 Mar;86(3):662-7. doi: 10.1097/00000539-199803000-00042. PMID: 9495434. Eger EI 2nd. Compound A: does it matter? Can J Anaesth. 2001 May;48(5):427-30. doi: 10.1007/BF03028302. PMID: 11394507. Eger EI 2nd, Gong D, Koblin DD, Bowland T, Ionescu P, Laster MJ, Weiskopf RB. Dose-related biochemical markers of renal injury after sevoflurane versus desflurane anesthesia in volunteers. Anesth Analg. 1997 Nov;85(5):1154-63. doi: 10.1097/00000539-199711000-00036. PMID: 9356118. Eger EI 2nd, Koblin DD, Bowland T, Ionescu P, Laster MJ, Fang Z, Gong D, Sonner J, Weiskopf RB. Nephrotoxicity of sevoflurane versus desflurane anesthesia in volunteers. Anesth Analg. 1997 Jan;84(1):160-8. doi: 10.1097/00000539-199701000-00029. PMID: 8989018. Feldman JM, Hendrickx J, Kennedy RR. Carbon Dioxide Absorption During Inhalation Anesthesia: A Modern Practice. Anesth Analg. 2021 Apr 1;132(4):993-1002. doi: 10.1213/ANE.0000000000005137. PMID: 32947290. Fukuda H, Kawamoto M, Yuge O, Fujii K. A comparison of the effects of prolonged (>10 hour) low-flow sevoflurane, high-flow sevoflurane, and low-flow isoflurane anaesthesia on hepatorenal function in orthopaedic patients. Anaesth Intensive Care. 2004 Apr;32(2):210-8. doi: 10.1177/0310057X0403200208. PMID: 15957718. Keijzer C, Perez RS, de Lange JJ. Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model. Acta Anaesthesiol Scand. 2007 Jan;51(1):31-7. doi: 10.1111/j.1399-6576.2006.01187.x. Epub 2006 Nov 10. PMID: 17096668. Kennedy RR, Hendrickx JF, Feldman JM. There are no dragons: Low-flow anaesthesia with sevoflurane is safe. Anaesth Intensive Care. 2019 May;47(3):223-225. doi: 10.1177/0310057X19843304. Epub 2019 May 24. PMID: 31124374. Kharasch ED, Frink EJ Jr, Artru A, Michalowski P, Rooke GA, Nogami W. Long-duration low-flow sevoflurane and isoflurane effects on postoperative renal and hepatic function. Anesth Analg. 2001 Dec;93(6):1511-20, table of contents. doi: 10.1097/00000539-200112000-00036. PMID: 11726433. Mazze RI, Jamison RL. Low-flow (1 l/min) sevoflurane: is it safe? Anesthesiology. 1997 Jun;86(6):1225-7. doi: 10.1097/00000542-199706000-00001. PMID: 9197289. McGain F, Bishop JR, Elliot-Jones LM, Story DA, Imberger GL. A survey of the choice of general anaesthetic agents in Australia and New Zealand. Anaesth Intensive Care. 2019 May;47(3):235-241. doi: 10.1177/0310057X19836104. Epub 2019 May 15. PMID: 31088129.

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24: Is low flow anesthesia with sevoflurane safe?

David Hao, MD

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