Vapor: If we can’t live with it, can we live without it?

Reid Rubsamen, M.D.

Staff Anesthesiologist

OR Medical Director

John Muir Medical Center

Walnut Creek, California

Relevant Financial Relationships: None

• I will be speaking about drugs for the induction and maintenance of anesthesia and about intra-operative awareness monitoring.

• I paid my own way to this meeting and I am not a paid consultant to any relevant companies.

OCF3

F F

F

F

F

CF3

O

CF3

F

Sevoflurane

F

F

F

Cl

O

F

F

Desflurane

Isoflurane

3M Dry Cleaning Fluid

OCF3

CF3

F

Motivation

• Inhalational anesthetics are basically medical grade organic solvents.

• New technology makes it possible to reduce or eliminate vapor from anesthetic practice.

• I have conducted approximately 2000 anesthetics with total intravenous anesthesia (TIVA) without prophylactic use of anti-emetic drugs and without vapor or nitrous oxide.

• Patients wake up more smoothly compared with my own experience using vapor.

Dramatic Short Term Side Effect Reduction With TIVA

• Very dramatic reduction of post operative nausea/vomiting.

• Less dysphoria at wake-up.

• Essential elimination of laryngospasm on emergence.

TIVA Can Be Used Widely

• Oxygen/air/propofol/opiates +/- muscle relaxants.

• Spontaneous breathing with laryngeal mask airway is not a problem.

• Need propofol pump and level of consciousness monitoring.

• Sevoflurane is the preferred induction agent for small children without an IV.

Vapor is the Easy Chair

• Muscle relaxation included.

• Awareness not a problem.

• Hypertension “management.”

• End tidal gas analysis ensures robustness.

TIVA Workload is Higher for the Anesthesiologist

• Awareness risk requires monitoring.

• Higher doses of muscle relaxant required.

• Blood pressure management with TIVA is a-la-carte.

• Psychologically very difficult for anesthesiologists to use no vapor at all.

The Future?

• Short term benefits of eliminating vapor from anesthesia practice are compelling.

• TIVA can be widely used.• Are there long term toxic effects of vapor

and/or TIVA on children or adults?• Need prospective, controlled TIVA versus

vapor clinical trial.• Need more technology to make TIVA easier

to do.

Conclusions

• TIVA can essentially replace the use of vapor except for the important pediatric application of inhalation induction for which sevoflurane is the preferred drug.

• The favorable short term side effect profile of TIVA compels me to avoid the use of vapor in my practice where possible.