Original Article
Arrhythmia incidence and associated factors during volatile induction of general anesthesia with sevoflurane: a retrospective analysis of 950 adult patients☆,☆☆

https://doi.org/10.1016/j.accpm.2021.100878Get rights and content

Highlights

  • •

    Incidence of arrhythmia during induction of anesthesia with sevoflurane was 17.3% in adults.

  • •

    High sevoflurane concentration may be associated with arrhythmia during induction.

  • •

    Careful control of sevoflurane concentration during induction is required.

Abstract

Background

Sevoflurane has been used to induce anaesthesia in adults due to its suitability for airway management and haemodynamic stability. Few studies have reported arrhythmia during volatile induction with sevoflurane in adults. Here, we investigated the incidence of arrhythmia and risk factors associated with its occurrence during sevoflurane induction of anaesthesia in adults.

Patients and Methods

We retrospectively analysed 950 adult patients who underwent elective ear nose and throat surgery with volatile induction using sevoflurane between May and December 2015. The incidence of arrhythmia and the factors associated with its development were analysed.

Results

Arrhythmia was observed in 164 (17.3%) of 950 adult patients. The most frequently observed arrhythmia was sinus tachycardia (heart rate > 120 bpm) (77 patients, 47.0%). The multivariable logistic analysis showed four independent risk factors: age (odds ratio [OR] = 0.984, 95% confidence interval [CI] = 0.973−0.996, p = 0.006), coronary artery disease (OR = 3.749, 95% CI = 1.574–8.927, p = 0.003), maximal concentration (8 vol%) of sevoflurane from the start of induction (OR = 2.696, 95% CI = 1.139–6.382, p = 0.024), and maintenance of 8 vol% sevoflurane concentration after eyelash reflex loss (OR = 1.577, 95% CI = 1.083–2.296, p = 0.018). The risk of hypotension was greater in patients in whom arrhythmia occurred, although blood pressure recovered to baseline after the concentration of sevoflurane was adjusted.

Conclusions

We recommend that the sevoflurane concentration be gradually increased with continuous and vigilant electrocardiogram and blood pressure monitoring. The sevoflurane concentration should be adjusted after sufficient unconsciousness is reached.

Introduction

The advantages of volatile induction include smooth transition to anaesthesia maintenance [1], adequate anaesthetic depth conditions [2] for airway management without the use of muscle relaxants or opiates, and good haemodynamic stability [3], [4], [5]. It is suitable for outpatient anaesthesia in adults because of its rapid awakening and recovery characteristics [6]. Sevoflurane is considered a safe volatile anaesthetic agent due to its reduced effects on the conduction system and lack of aggravation of cardiac arrhythmia induced by catecholamines [7]. Sevoflurane exhibits low airway stimulation and a low blood-gas partition coefficient to facilitate volatile anaesthesia induction and maintenance.

High concentrations during induction may cause arrhythmia. Adverse cardiac arrhythmias such as nodal rhythm with bradycardia [8], isorhythmic atrioventricular dissociation [7], and prolongation of corrected QT (QTc) interval [9], [10], [11], [12] have been reported.

This single large centre retrospective analysis aimed to investigate the incidence of arrhythmia and the factors associated with arrhythmia development during general anaesthesia induction with sevoflurane. Haemodynamic parameters were monitored to evaluate the clinical significance of arrhythmia during the induction with sevoflurane.

Section snippets

Patients

The present study was approved by our Institutional Review Board (approval No. 2017-0446), which waived the requirement for written informed consent. This manuscript adheres to the applicable STROBE guidelines. The study was conducted in accordance with the Declaration of Helsinki of the World Medical Association for experiments involving humans. We reviewed the electronic medical and anaesthesia records to collect information on patients with an American Society of Anesthesiologists (ASA)

Results

In total, 950 adult patients met the inclusion and exclusion criteria and were included in the current analysis. Of these, 580 (61.1%) were male and 370 (38.9%) were female, with a mean age of 48.3 ± 15.5 years. The patients underwent septal reconstruction (17.1%), laryngeal microsurgery (16.5%), endoscopic sinus surgery (10.4%), tympanoplasty with mastoidectomy (9.4%), excision (7.9%), thyroidectomy (6.2%), parotidectomy (5.2%), open rhinoplasty (4.5%), tonsillectomy (4.4%), and other

Discussion

We found that the incidence of arrhythmia during volatile induction with sevoflurane in adults was 17.3%. Young adult age, CAD, induction with a maximal 8 vol% of sevoflurane, and maintenance of a maximal concentration beyond the time of eyelash reflex loss were independent risk factors associated with the occurrence of arrhythmia during induction of anaesthesia with sevoflurane. Sevoflurane induction did not cause any serious complication during the surgery.

In paediatric patients, the

Conclusion

We have reported the incidence of arrhythmia during anaesthesia induction with sevoflurane. Age, CAD, initial maximal concentration (8 vol%) of sevoflurane, and the maintenance of maximal concentration after eyelash reflex loss were independent risk factors for the occurrence of arrhythmia. Our results suggest that the sevoflurane concentration should be gradually increased and adjusted after sufficient unconsciousness is reached while carefully monitoring ECG and blood pressure.

Human and animal rights

The authors declare that the work described has been carried out in accordance with the Declaration of Helsinki of the World Medical Association revised in 2013 for experiments involving humans as well as in accordance with the EU Directive 2010/63/EU for animal experiments.

Informed consent and patient details

The authors declare that this report does not contain any personal information that could lead to the identification of the patient(s).

Disclosure of interest

The authors declare that they have no known competing financial or personal relationships that could be viewed as influencing the work reported in this paper.

Funding

This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI18C2383).

Author contributions

All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship.

Availability of data and materials

The datasets used and analysed in the current study are available from the corresponding author on reasonable request.

CRediT authorship contribution statement

Jungpil Yoon: Data curation, Visualisation, Formal analysis, Writing - original draft. Jaewon Baik: Investigation, Data curation, Visualisation, Writing - review & editing. Min Soo Cho: Validation, Writing - review & editing. Jun-Young Jo: Investigation, Data curation. Sugeun Nam: Investigation, Data curation. Sung-Hoon Kim: Software, Validation, Visualisation, Funding acquisition, Writing - review & editing. Seungwoo Ku: Investigation, Methodology, Data curation, Writing - review & editing.

Acknowledgments

The authors would like to thank: Seong-Sik Cho, MD, PhD (Department of Occupational and Environmental Medicine, College of Medicine, Dong-A University) for the statistical support, and Editage (www.editage.co.kr) for English language editing.

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    • Cited by (5)

    ☆

    This work was presented in part as J. Baik's M.S. thesis at the University of Ulsan College of Medicine (2017).

    ☆☆

    This work was partly presented at the 34th Congress of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine held in Malmö, Sweden (2017).

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