Comparison of the Impact on the Extubation Between Desflurane and Sevoflurane in Obese Patients Undergoing Thyroidectomy

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1 2017 2nd International Conference on Advanced Materials Science and Environment Engineering (AMSEE 2017 ISBN: Comparison of the Impact on the Extubation Between and in Obese Patients Undergoing Thyroidectomy Chun-lu ZHANG, De-wu ZENG, Lu CHEN, Wei-kang WANG and Peng CHEN * Department of Anesthesiology, China-Japan Union Hospital, Ji Lin University, Changchun, China *Corresponding author Keywords:,, Obese, Thyroid surgery, Recovery quality. Abstract. Objective: Comparison of the impact on the extubation between desflurane and sevoflurane in obese patients undergoing thyroidectomy. Method: A total number of 60 obesity cases aging between 32~60 were selected, randomly divided into 2 groups, named Group (30 cases and Group(30cases. Patients were required for anesthesia detection. Penehyclidine 0.5mg. Induction of anesthesia was 1ED95 rocuronium bromide 0.3 mg/kg, midazolam 2mg, propofol 2 mg/kg and sufentanil 0.5 μg/kg.the drugs facilitate tracheal intubation with nerve monitoring function and mechanical ventilation, tidal volume 8~10ml/kg, respiratory rate12/min. Maintained the anesthesia with 1.2~1.4 MAC of desflurane or sevoflurane. Stopping medication after surgery. We recorded the OAA/S scores at 5min, 10min, 20min and 30min later after extubation and Riker agitation sedation scores. SPSS 20.0 software was used to analysis results. Results: Compared with sevoflurane, desflurane has a certain clinical application advantages applying in obese patients with nerve monitoring complexity thyroidectomy, showing short recovery and extubation time obviously. But desflurane showed a higher incidence of postoperative agitation than sevoflurane. Introduction The overweight patients often have the physiological changes in major organs and some diseases, such as cardiovascular and cerebrovascular diseases, diabetes, sleep - breathing disorders, etc[1]. The changes in the anatomy of the throat will bring great risks to anesthesia management. It has been found that[2] there was significant increase risk of complications such as upper airway obstruction and bronchospasm in overweight patients during the operation. And the ability of these patients to tolerate hypoxia fade, prone to hypoxemia. In addition, there is excessive body fat in the obese patients,high fat soluble anesthetic drugs will accumulate in the fat, which lead to long drug metabolism time and wake up delayed. Thyroid disease is increasing in clinic, and recurrent laryngeal nerve injury is the most common and serious complication of thyroid surgery. Sun Hui [3] found that conventional naked eye recognition can reduce the damage of recurrent laryngeal nerve, but it can not meet the needs of complex thyroid surgery. Intraoperative nerve monitoring combined with naked eye recognition can greatly improve the recognition rate of recurrent laryngeal nerve. Many foreign scholars [4-7] have similar consensus, so the use of intraoperative monitoring of recurrent laryngeal nerve in thyroid surgery has become an undeniable trend. The key of thyroid IONM anesthesia is induction, and one of the difficulties is the correct use of non depolarizing muscle relaxants. The use of muscle relaxants and residues may interfere with the monitoring results of EMG signals, resulting in false positive results of recurrent laryngeal nerve continuity. The Liu Hongyan [8] study showed that 2 times ED95 of rocuronium (0.6mg/kg - induced anesthesia combined with seven halothane is suitable for monitoring the function of recurrent laryngeal nerve in thyroid surgery. In the absence of intraoperative nerve monitoring, Chen Peng [9-10] in the application of small doses of non depolarizing muscle relaxant induced research showed that 2 times ED95 rocuronium clinical effect time was 36min and 1 times the clinical effect of rocuronium ED95 was shorter than 30min and the monitoring of recurrent laryngeal nerve from the insertion of the endotracheal tube to the procedure required at 272

2 least 30min. The purpose of our study is that how to improve the recovery quality of overweight patients with thyroid surgery under high line nerve monitoring, reduce the postoperative intubation time, thereby reduce the adverse reactions such as glottic edema and vocal cord injury. Moshchev DA [11] found that the low solubility of desflurane in the blood and tissues of the organism caused it to be rapidly absorbed and eliminated. It is characterized by minimal metabolism and less interaction with sodium calcium., the most effective inhalation anesthetic with minimal blood gas partition coefficient, has strong controllability. At the same time, the oil / gas partition coefficient of desflurane was The solubility of blood tissue is lower, and the patients with overweight are more controllable. It is worth looking forward to to reduce the adverse reaction caused by anesthesia during extubation that desflurane is used in nerve monitoring in thyroid surgery. Materials and Methods General Information The study was approved by the Ethics Eommittee of the China-Japan Union Hospital of Jilin University.And the comprehension and accept. Scheduled general anesthesia, selective complex thyroidectomy,aged years patients. Key Inclusion Criteria:a: Operative time >3h, b: Obese patients. Body mass index: BMI= weight (kg / height (m2, BMI>25.Key Exclusion Criteria:Serious history of hypertension, coronary heart disease,arrhythmia, narcotic drugs allergy, beta blockers medication, and mental diseases or taking antidepressant drugs. The patients were divided into two groups randomly with numeration table,estimated 30 cases in desflurane group (D group =30 and 30 cases in sevoflurane(s group =30. Anesthesia Method All patients are opened vein circuits by nurses after entering into the operating rooms,routinely monitored with Blood pressure(bp, Heart rate(hr, Electrocardiograp(ECG, Bispectral(BIS, End-tidal CO2 partial pressure(etco2, SpO2. Induction anesthesia: All patients are inducted with 1ED95 rocuronium bromide 0.3 mg/kg, midazolam 2 mg, propofol 2 mg/kg and sufentanil 0.5 μg/kg. When patients have the condition of tracheal intubation under the visual laryngoscope, the special thyroid tracheal tube which have nerve monitoring function are intubated through the mouth. Fix the tracheal tube when thyroid physicians confirm accurate position by visual laryngoscope. Maintenance anesthesia: Mechanical ventilation, VT 6-8ml/kg, RR12-20bpm,EtCO mmHg, total inhalation anesthetic maintenance during the operation. The experimental group is desflurane group, while the contrast group is sevoflurane group. The depth of anesthesia was maintained 1.2~1.4MAC both in D and S groups, monitoring and maintaining by BIS. At the end of the operation, the inhalation anesthetic was stopped and adjusting the oxygen flow 5-6 L/min. When the MAC figure is lower than 0.1,return to the hand controlled respiration. Remove the tubes when the patients are totally recovery of spontaneous breathing,swallowing reflex, throat reflex, cough reflex and fully awake, respond to the call, the tidal volume and the minute ventilation volume return to normal index. Monitoring Index Record the operation time and the time from now on stopping the anesthesic to recovery of spontaneous breathing,opening eyes when cell their names, follow the instruction, extubation and recovery of orientation. Perform OAA/S scores [12] at 5min, 10min, 20min, 30min after extubation. (Standard for evaluation: 5 points, react quickly when call names with normal tone; 4 points, a cold response when call names with normal tone; 3 points, response to repeated and loudly calling names; 2 points, response to mild shaking shoulders or heads; 1points, no response to the lightly shaking. Whether the patients cough,nausea or vomit would be observered and recorded. The patients would treated with Riker sedation-agitation score [13], and the appropriate score is controlled at 3~4 points. (Standard for evaluation, 1 points, can not wake up, no response to malignant stimulation

3 points,over calm,autonomous movement but not be able to obey orders or communication, a slight response to physical stimulation.3 points, calm, can obey simply orders with light shaking or verbal stimulation,and fall asleep fast; 4 minutes, quiet and cooperative,be able to obey orders, easy to wake up; 5 points, restlessness or anxiety, be quiet with discouraging or words to console; 6 points, very restless, the performance is biting on the endotracheal tube, irritability, and need for protective restraint or repeated language discourage. 7 points, dangerous restlessness, try to remove all kinds of catheter, pull endotracheal catheter, repeated struggle or attacking staffs.the satuations of pain on the throat and the results of fiber laryngoscope would be recorded on the next day after the operation. Statistical analysis SPSS 20.0 software is used for process the date, t- test for statistical analysis, p<0.05 is esteemed as the significant difference. Result 1. There was no significant difference between the two groups in age, BMI index and operation time. See Table 1. Table 1. Comparison of age, BMI index and operation time between desflurane group and seven halothane group. age BMI index operation time ±8.452(n= ±6.856(n= ±1.671(n= ±1.635(n= ±17.304( ±15.869( n=30 n=30 P The recovery time of spontaneous breathing, the time of eye opening, the time of instruction, extubation time, and the recovery time of the desflurane group were shorter than that of seven halothane group, the difference was statistically significant(p<0.05. See Table 2. Table 2. Comparison of the recovery time between desflurane group and seven halothane group P t Line ±2.177(n= ±4.303(n=30 < Line ±2.515(n= ±4.746(n=30 < Line ±2.716(n= ±4.978(n=30 < Line ±2.837(n= ±4.642(n=30 < Line ±2.739(n= ±5.778(n=30 < The scores of 5min, 10min, 20min, 30min after extubation were analyzed by OAA/S, and there was no statistical significance in p>0.05. See Table 3. Table 3. Comparison of OAA/S score between desflurane group and seven halothane group. P t Time Point ±0.650(n= ±0.760(n= Time Point ±0.568(n= ±0.568(n= Time Point ±0.000(n= ±0.277(n= Time Point ±0.000(n= ±0.000(n= The incidence of side effects such as cough, nausea and vomiting were similar in the two groups, there was no significant difference. See Table 4. t 274

4 Table 4. Comparison of the incidence of cough, nausea and vomiting in desflurane group and seven halothane group. P t Cough Nausea or vomiting The statistical results of postoperative agitation score of desflurane group and seven halothane group P < 0.05, the difference was statistically significant. See Table 5. Table 5. Comparison of RAAS score between desflurane group and seven halothane group. P t RAAS 4.000± ±0.664 < Two groups of patients after the operation on the second day of throat pain and fiber optic laryngoscopy results were similar, no abnormalities. Summary The recurrent laryngeal nerve injury is the most serious complication in thyroid surgery [14-17]. According to recent reports, the incidence of recurrent laryngeal nerve loss was 1%~14%. It has been reported in the literature that the location of the intraoperative neuromonitoring during thyroidectomy (IONM can help doctors prevent the occurrence of nerve injury. However, the use of residual neuromuscular blockade during anesthesia induction may interfere with the monitoring results of EMG signals, resulting in false positive results of recurrent laryngeal nerve continuity. Peng Chen's study of the use of non conventional depolarizing muscle relaxants, and the use of the whole anesthetic regimen in the promotion of domestic anesthesia provides a new method for our anesthesia. The object of this study choose general anesthesia patients who complexity thyroid resection performer, the operation schedule > 3 h, body mass index, BMI>25 kg/m2 of obese patients. Because of the small dosage of non depolarizing muscle relaxants, the residual of the muscle relaxants is very small, the depth of anesthesia is completely controlled by inhalation anesthetics. All the patients with inhalation anesthesia recovered quickly, so they had higher requirements on the quality of recovery. Improper treatment, patients in the perioperative period of hypoxemia, cough, and other adverse reactions will be significantly higher. Obese patients showed an increasing trend in our country, the risk of obesity was significantly higher than the general patients. Based on the above reasons, it is of great practical significance to explore the anesthetic management of obese patients undergoing thyroid surgery. The results showed that there was no significant difference between the two groups in gender, age, height, weight and operation time. The recovery time of spontaneous breathing, the time of eye opening, the time of instruction, extubation time, and the recovery time of the directional force were shorter than those of seven halothane group (P < The results showed that compared with seven sevoflurane, desflurane was more effective in the treatment of obese patients with thyroid gland. The reason may be that desflurane is smaller and lighter than seven halothane, and the blood / gas partition coefficient of desflurane is less than that of seven halothane, which has better controllability. The reason may be that desflurane is smaller and lighter than seven halothane, and the blood / gas partition coefficient of desflurane is less than that of seven halothane, which has better controllability. So this application in patients with obesity have a certain advantage, Dexter [18-19] are demonstrated through simulation studies, compared with seven halothane, application of desflurane may reduce the average extubation time and reduce the variability of the extubation time of 20%-30%. To extubation after 5 min, 10 min, 20 min, 30 min of the four moment OAA/S score on the statistical analysis showed that application of inhalation anesthesia, two groups of patients with postoperative sedation are good after regain consciousness, to ideal. The incidence of side effects such as cough, nausea and vomiting was similar in the two groups during the extubation period. There was a statistical difference in the postoperative agitation score 275

5 between the desflurane group and the seven halothane group. The incidence of agitation in the halothane group was higher than that in the seven halothane group. But the desflurane group restlessness patients lasted very short, the longest continuous time 4 minutes. The reason may be that compared with seven sevoflurane, desflurane anesthesia is weak, and the patient may appear to be active when the concentration of desflurane is higher. In order to reduce the incidence of iatrogenic injury caused by extubation, the accumulation of desflurane in the body is very small, so the patient can quickly get out of the state of agitation. There was no difference in postoperative recovery, nausea and vomiting. There was no significant difference between the two groups in the throat pain and fiber laryngoscope after the operation for second days.due to the limited number of patients in this experiment, the result of this experiment is affected by the number of samples.above all, the application of desflurane in the anesthesia of thyroid surgery in obese patients under the monitoring of nerve, the recovery time is short, the recovery quality is high, the airway protective reflex is fast, and the patient is safer. However, attention should be paid to avoid the emergence of restlessness, and ready to deal with. References [1] Xiao-Shan Xiao, Wei-Feng Tu. Preoperative evaluation and preparation of patients with over obesity [J]. The Journal of Practical Medicine, 2004, 20(5: [2] Hai-Tong Liu, Jun-Yan Yao, Shi-Tong Li. Comparison of desflurane and seven halothane in clinical application [J]. Shanghai Medical Journal, 2015, 38(2: [3] Hui Sun, Xiao-Li Liu, Da-Qi Zhang. Clinical application of protection and monitoring of recurrent laryngeal nerve in thyroid surgery [J]. Chinese Journal of Bases and Clinics in General Surgery, 2010, 17(8: [4] Hermann M., Hellebart C., Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury [J]. Ann Surg, 2004, 240(1: [5] Thomusch O., Machens A., Sekulla C., et al. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany [J]. World J Surg, 2000, 24(11: [6] Johnson S, Goldenberg D. Intraoperative monitoring of the recurrent laryngeal nerve during revision thyroid surgery [J]. Otolaryngol Clin North Am, 2008, 41(6: [7] Dionigi G., Boni L., Rovera F., et al. Neuromonitoring and video-assisted thyroidectomy: A prospective, randomized case-control evaluation [J]. Surg Endosc, 2009, 23(5: [8] Hong-Yan Liu, Qi-Ya Hu. Impacts of different doses of rocuronium on intraoperative recurrent laryngeal nerve monitoring during thyroid surgery [J]. Journal of Clinical Anesthesiology, 2015, 31(5: [9] Peng Chen, Feng Liang. The effect of different concentrations of Rocuronium Bromide induction on the introperative recurrent laryngeal nerve monitoring of the patients with thyroid operation [J]. Chinese Journal of Laboratory Diagnosis, 2014, 18(9: [10] Yang-Dong Han, Peng Chen. The effect on introperative recurrent laryngeal nerve monitoring: 1 ED95 of cisatracurium or relaxation-free anesthesia induction [J]. Chinese Journal of Experimental Surgery, 2014, 31(9: [11] Moshchev DA,Lubnin Alu. Application of desflurane in anaesthesiology[j].anesteziologiia i reanimatologiia,2014,2(1: [12] De Hert S., Moerman A. [J]. F1000Research 2015; 4 (F1000 Faculty Rev :

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