Narrative Review of Systemic Inflammatory Response Mechanisms in Cardiac Surgery and Immunomodulatory Role of Anesthetic Agents

Although surgical techniques and perioperative care have made significant advances, perioperative mortality in cardiac surgery remains relatively high. Single? or multiple?organ failure remains the leading cause of postoperative mortality. Systemic inflammatory response syndrome (SIRS) is a common trigger for organ injury or dysfunction in surgical patients. Cardiac surgery involves major surgical dissection, the use of cardiopulmonary bypass (CPB), and frequent blood transfusions. Ischemia?reperfusion injury and contact activation from CPB are among the major triggers for SIRS. Blood transfusion can also induce proinflammatory responses. Here, we review the immunological mechanisms of organ injury and the role of anesthetic regimens in cardiac surgery

Hipertermia maligna / Malignant hyperthermia

Resumen: La hipertermia maligna es un raro desorden farmacogenético potencialmente mortal, que se presenta como una respuesta hipermetabólica a los anestésicos volátiles y relajantes musculares despolarizantes en individuos susceptibles. Esta susceptibilidad se asocia a mutaciones en tres genes: RYR1, CACNA1S y STAC3. Puede manifestarse con síntomas leves o como una crisis fulminante, con rabdomiólisis severa, fibrilación ventricular e insuficiencia renal y circulatoria aguda, por lo tanto, el pronóstico depende de qué tan pronto se sospeche del diagnóstico y qué tan rápido se inicie el tratamiento. El diagnóstico definitivo se basa en una prueba de sensibilidad en biopsia muscular fresca y en pruebas genéticas. La mejor manera de prevenir un evento es la detección precoz de los pacientes susceptibles así como contar con el equipo para responder ante una crisis en cada centro donde se administren anestésicos volátiles y la capacitación del personal. Esta revisión sintetiza los conceptos actuales clínicos y biomédicos para detección, prevención, diagnóstico y manejo de la hipertermia maligna.

Abstract: Malignant hyperthermia is a rare, life-threatening pharmacogenetic disorder which presents as a hypermetabolic response to volatile anesthetics and depolarizing muscle relaxants in susceptible individuals. This susceptibility is associated with mutations in three genes: RYR1, CACNA1S and STAC3. Can manifest with mild symptoms or as a fulminant crisis, with severe rhabdomyolysis, ventricular fibrillation and acute renal and circulatory failure, therefore the prognosis depends on how soon the diagnosis is suspected and how fast treatment is started. The definitive diagnosis is based on a fresh muscle biopsy sensitivity test and genetic testing. The best way to prevent an event is the early detection of susceptible, as well as have equipment to respond to a crisis in each center where volatile anesthetics are administered and the training of staff. This review synthesizes current clinical and biomedical concepts for detection, prevention, diagnosis and management of malignant hyperthermia.

Association between anesthesia regimen and postoperative infection in patients undergoing cardiac surgery: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective     To evaluate the association between anesthesia regimen (volatile or intravenous anesthetics) and postoperative infection in adult cardiac patients undergoing cardiac surgery. Methods    The clinical data of 496 elective adults undergoing cardiac surgery under cardiopulmonary bypass from June 2019 to June 2020 in West China Hospital of Sichuan University were retrospectively analyzed, including 251 females and 245 males with an average age of 54.1±11.4 years. American Society of Anesthesiologists grade was Ⅰ-Ⅲ. There were 243 patients in a volatile group with sevoflurane or desflurane, and 253 patients in an intravenous anesthesia group with propofol. The primary outcome was the incidence of infection within 30 days after cardiac surgery, including pulmonary infection, surgical site infection, sepsis, and urinary tract infection. The secondary outcomes were duration of mechanical ventilation, incidence of reintubation, ICU stay, postoperative length of hospital stay and total hospitalization cost. Results     A total of 155 (31.3%) patients developed postoperative infection within 30 days, with an incidence of 32.9% in the volatile group and 29.6% in the intravenous anesthesia group. There was no statistical difference in the incidence of infection (RR=1.111, 95%CI 0.855 to 1.442, P=0.431) or the secondary outcomes (P>0.05) between the two groups. Conclusion     The anesthesia regimen (volatile or intravenous anesthetics) has no association with the risk of occurrence of postoperative infection in adult  patients undergoing elective cardiac surgery with cardiopulmonary bypass.

Inhalational anesthesia maintenance with the Janus facial mask for transcatheter aortic-valve replacement: a case series / Manutenção da anestesia inalatória com a máscara facial Janus para substituição de válvula aórtica transcateter: uma série de casos

Abstract Background and objectives Aortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full-face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation. Methods A case series observational study that included five patients with critical aortic stenosis that underwent inhalational anesthesia with sevoflurane for transcatheter aortic valve replacement in a hybrid room of a teaching hospital. Standard monitors and bispectral index were used, followed by inhalational induction and placement of the Janus mask. Anesthesia was maintained with sevoflurane. Patients were transferred to intensive care unit after the procedure. Complications related to the mask use, transesofageal echocardiography accessibility and respiratory implications to the patients were recorded. Results All procedures were uneventful and no major complications were observed intraoperatively. One patient presented CO2 retention (50 mmHg) and sevoflurane leak around the central opening of the mask, both without clinical significance. Conclusions The use of inhalational anesthesia with the facial mask Janus is a safe and efficient alternative to general anesthesia with tracheal intubation for transcatheter aortic valve replacement and can easily accommodate the use of transesophageal echocardiography intraoperatively.

Resumo Justificativa e objetivos A estenose aórtica é o tipo mais comum de doença valvular cardíaca. A substituição percutânea de válvula aórtica tornou-se a alternativa para pacientes cirúrgicos considerados de alto risco. A ventilação mecânica controlada com intubação traqueal tem sido a escolha para esse tipo de procedimento; porém, o uso de ventilação não invasiva em pacientes cardíacos mostrou ser benéfico. Janus é uma nova máscara facial que permite a aplicação de suporte à VNI durante a anestesia. Nosso objetivo primário foi avaliar a viabilidade da substituição transcateter de valva aórtica com monitoração ecocardiográfica transesofágica prolongada sob sedação inalatória profunda através de uma nova máscara para ventilação não invasiva. Métodos Estudo observacional de série de casos que incluiu cinco pacientes com estenose aórtica em fase crítica, submetidos à anestesia inalatória com sevoflurano para substituição transcateter de valva aórtica em uma sala híbrida de um hospital universitário. Monitores padrão e índice bispectral foram usados, seguidos de indução inalatória e colocação da máscara Janus. A anestesia foi mantida com sevoflurano. Os pacientes foram transferidos para a unidade de terapia intensiva após o procedimento. As complicações relacionadas ao uso da máscara, a acessibilidade da ecocardiografia transesofágica e as implicações respiratórias para os pacientes foram registradas. Resultados Todos os procedimentos transcorreram sem incidentes e não foram observadas complicações maiores no intraoperatório. Um paciente apresentou retenção de CO2 (50 mmHg) e vazamento de sevoflurano em torno da abertura central da máscara, ambos sem significância clínica. Conclusões O uso de anestesia inalatória com a máscara facial Janus é uma opção segura e eficiente à anestesia geral com intubação traqueal para substituição transcateter de valva aórtica e pode facilmente acomodar o uso de ecocardiografia transesofágica no intraoperatório.

The effect of low fresh gas flow rate on sevoflurane consumption / 대한마취과학회지

BACKGROUND: In an era of medical cost containment, cost-effectiveness has become a major focus in healthcare. The effect of a new policy on the use of low fresh gas flow during maintenance of general anesthesia with volatile anesthetics was evaluated. METHODS: The numbers and duration of general anesthesia cases using sevoflurane 5 weeks prior to and 15 weeks after policy implementation were retrieved from the electronic medical records database. The number of sevoflurane bottles consumed was also assessed. The anesthesia hours per bottle of sevoflurane were compared before and after policy implementation. RESULTS: The number of anesthesia hours performed per bottle of sevoflurane increased by 38.3%. The effect varied over time and tended to fade with time. CONCLUSIONS: The implementation of a low fresh gas flow rate policy effectively reduces the amount of sevoflurane consumed for the same duration of anesthesia.

Sevoflurane causes less arrhythmias than desflurane after off-pump coronary artery bypass grafting: A pilot study.

Background: Volatile anesthetics provide myocardial protection during cardiac surgery. Sevoflurane and desflurane are both efficient agents that allow immediate extubation after off-pump coronary artery bypass grafting (OPCABG). This study compared the incidence of arrhythmias after OPCABG with the two agents. Materials and Methods: Forty patients undergoing OPCABG with immediate extubation and perioperative high thoracic analgesia were included in this controlled, double-blind study; anesthesia was either provided using 1 MAC of sevoflurane (SEVO-group) or desflurane (DES-group). Monitoring of perioperative arrhythmias was provided by continuous monitoring of the EKG up to 72 hours after surgery, and routine EKG monitoring once every day, until time of discharge. Patient data, perioperative arrhythmias, and myocardial protection (troponin I, CK, CK-MB-ratio, and transesophageal echocardiography examinations) were compared using t-test, Fisher's exact test or two-way analysis of variance for repeated measurements; P < 0.05. Results: Patient data and surgery-related data were similar between the two groups; all the patients were successfully extubated immediately after surgery, with similar emergence times. Supraventricular tachycardia occurred only in the DES-group (5 of 20 patients), atrial fibrillation was significantly more frequent in the DES group versus SEVO-group, at five out of 20 versus one out of 20 patients, respectively. Myocardial protection was equally achieved in both groups. Discussion: Ultra-fast track anesthesia using sevoflurane seems more advantageous than desflurane for anesthesia, for OPCABG, as it is associated with significantly less atrial fibrillation or supraventricular arrhythmias after surgery.

Thermoregulatory responses of sevoflurane, desflurane, and isoflurane during gynecologic laparoscopic surgery / 대한마취과학회지

BACKGROUND: Core temperature decreases rapidly after the induction of general anesthesia, because the heat is redistributed to peripheral tissues. Thermoregulatory responses of volatile anesthetics have been tested, but their effects have not been directly compared. Therefore, we evaluated the thermoregulatory responses to sevoflurane, desflurane, and isoflurane. METHODS: Sixty healthy patients scheduled for laparoscopic myomectomy or radical hysterectomy were allocated into three groups; Group S (sevoflurane, n = 20), Group D (desflurane, n = 20), and Group I (isoflurane, n = 20). Anesthesia was maintained with 1 minimum alveolar concentration (MAC) of sevoflurane, desflurane, and isoflurane in a 50/50 mixture of N2O/O2. Patients were maintained in a normovolemic and normocapnic state. The core temperature and forearm minus fingertip skin-temperature gradient (an index of peripheral vasoconstriction) were monitored after the induction of general anesthesia. RESULTS: Each of the seven patients given sevoflurane, desflurane, and isoflurane vasoconstricted at a core temperature of 35.3 +/- 0.5degrees C, 33.6 +/- 0.4degrees C, and 35.2 +/- 0.4degrees C, respectively. The vasoconstriction threshold was the lowest in patients anesthetized with desflurane. The core temperature gradient (Ti-Tf) was significantly higher in patients that were anesthetized with desflurane than in those that were anesthetized with sevoflurane or isoflurane. The core temperature of desflurane was significantly lower than that of sevoflurane or isoflurane 15 minutes after the induction of anesthesia until 180 minutes of anesthesia. CONCLUSIONS: These results indicate that the core temperature is maintained at a higher level in patients that have been anesthetized with sevoflurane or isoflurane than in those that have been anesthetized with desflurane.

K(ATP) channel / 한양의대학술지

Pharmacological preconditioning with volatile anesthetics is a phenomenon whereby a brief exposure to volatile anesthetic agents protects the heart from the potentially fatal consequences of a subsequent prolonged period of myocardial ischemia and reperfusion. Although not completely elucidated, the cellular and molecular mechanisms of pharmacological preconditioning appear to mimic those of ischemic preconditioning, the most powerful endogenous cardioprotective mechanism. Activation of ATP-dependent potassium (K(ATP)) channels in the myocardium plays an important cardioprotective role during ischemia. This article reviews current concepts and controversies regarding the specific roles of the mitochondrial and the sarcolemmal K(ATP) channels in pharmacological preconditioning by volatile anesthetics.

Anesthetic Management for a Patient with Congenital Insensitivity to Pain with Anhidrosis (CIPA): A case report / 대한마취과학회지

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare, autosomal-recessive disorder characterized by the clinical triad of indifference of pain, anhidrosis and heat intolerance.Because of their lack of autonomic response to noxious stimuli, the determination of adequate depth of anesthesia in the CIPA patient undergoing surgery is a major challenge.We experienced a patient with CIPA who had minor procedures three times under the general anesthesia, in which bispectral index (BIS) was maintained at 40-50 by adjusting sevoflurane concentrations with 50% nitrous oxide.The low end-tidal sevoflurane concentrations (<1.2 vol%) were required to keep the target BIS while vital signs remained stable throughout the surgery in each operation.BIS monitor may be a valuable tool to guide the depth of anesthesia in patients with CIPA.

Effects of Fresh Gas Flow Rate on the Ratio of Expired to Inspired Anesthetic Concentration / 대한마취과학회지

BACKGROUND: One way to make rapid increase in alveolar anesthetic concentration includes using high fresh gas flow rates. Fresh gas flow rates should be increased to compensate the amount of uptake either. This study was performed to elucidate optimal fresh gas flow rates for rapid induction by comparison of changes of ratio of expired to inspired concentration. METHODS: The study population was composed of 107 patients undergoing thyroidectomy. Patients were randomly allocated to one of three groups who received desflurane or sevoflurane or isoflurane. Each group was randomly subdivided into three groups who received one of the fresh gas flow rate: 2, 5 or 10 L/min. Inspired anesthetic concentration (Fi) and expiratory anesthetic concentration (Fe), delivered concentration (FD) were recorded. RESULTS: With same fresh gas flow rates, there were significant differences between Fe/Fi of desflurane, sevoflurane, isoflurane. With same anesthetics, Fe/Fi of desflurane and sevoflurane were not influenced by fresh gas flow rates. But Fe/Fi of isoflurane at 2 L/min was significantly lower than 5 L/min and 10 L/min. Fi/FD of desflurane at 10 L/min did not differ from sevoflurane. At 2 L/min and 5 L/min, Fi/FD of desflurane was highest and then sevofluane, isoflurane in that order. CONCLUSIONS: Because rates of Fe/Fi of desflurane and sevoflurane were not influenced by fresh gas flow rates, 2 L/min of fresh gas flow rates could be selected. However, considering the wash-in time in circuit, optimal choice of fresh gas flow rate for desflurane and sevoflurane could be 5 L/min, that of isoflurane be 10 L/min.

Practical Choice and Knowledge of Korean Anesthesiologists for Fresh Gas Flow / 대한마취과학회지

BACKGROUND: The inhalational anesthesia is performed by the administration of inhalational agents and fresh gases. Low and high flows have their own advantages and disadvantages. In Korea, many anesthesiologists use more than 2 L/min of fresh gas flow (FGF). This study was performed to analyze the practice and knowledge of FGF use by Korean Anesthesiologists. METHODS: A questionaire was sent to 122 anesthesiologists (15 university hospitals and 16 general hospitals) who attended the 47th Annual Autumn Meeting of the Korean Society of Anesthesiology in 2002. The questionaire covered topics dealing with inhalational agents, FGF, and safety systems for inhalational anesthesia practice. RESULTS: The most preferred inhalational anesthetic was sevoflurane (65.6%). 88.5% of respondents used more than 2 L/min of FGF. The majority of the respondents, however, did not consider the reasons for using certain levels of FGF. Only 27% of hospitals had pulse oximetry, capnogram or muti-gas analysis, fail-safe device, and a scavenging system. CONCLUSIONS: Many anesthesiologists, especially trainees, failed to consider the use of FGF during inhalational anesthesia. Therefore, special consideration should be given to the training and education of trainees about the proper of FGF.

Researches on relative genes determing sensitivity to volatile anesthetics / 第二军医大学学报

The use of genetic approaches to probe relative genes that control sensitivity to volatile anesthetics in intact model has recently emerged as the powerful tools and strategies in dissecting mechanisms of anesthesia. Multiple model organisms such as yeast, nematodes, fruitflies and mammals are currently being exploited, and a number of sensitive genes have been screened, with some of them being cloned, located, and function identified. The emerging technologies are likely to provide further great advances for elucidating the specific anesthetic molecular sites.

Preconditioning with desflurane, sevoflurane and isoflurane increase the preservation of adenosine triphosphate in anoxia-reoxygenation myocardial cells / 中国临床药理学与治疗学

Aim To study the effects of preconditioning with desflurane, sevoflurane and isoflurane on adenosine triphosphate (ATP) in anoxia-reoxygenation myocardial cells. Methods Rat ventricular myocytes, cultured for 4～5 days, were randomly allocated to five groups: Control group, anoxia-reoxygenation group and groups preconditioned with 1.5 MAC desflurane, sevoflurane or isoflurane following anoxia-reoxygenation. The content of intracellular ATP ,the activities of lactic dehydrogenase(LDH) and creatine kinase(CK), and the cell viability were measured at the end of experiment.Results Preconditioning with 1.5 MAC desfllurane, sevoflurane or isoflurane significantly attenuated the great reduction in ATP and cell viability and the increase of LDH and CK caused by anoxia-reoxygenation. There was a positive correlationship between ATP and cell viability,and a negatiue correlationship between LDH and CK (r was 0.83, -0.87 and -0.82 respectively, P

The influences of volatile anesthetic agents on rat liver mitochondrial electron transfer chain / 中华麻醉学杂志

Rat liver mitochondria were exposed to various conentrations of halothane,enflurane, isoflurane and sevoflurane. Electron transfer rates from NADH and succinate to cytochrome C were measured by scanning dual wavelength spectrophotometer. Statistical analysis of the data suggested that halothane at clinical or higher than clinical concentrations markedly inhibited activities of NADH-Cyt,C reductase.in contrast,no decrease occurred in the activities of NADH dehydrogenase,NADH-coenzyme Q reductase and enzymatical system of succinate chain. Enflurane,isoflurane and sevoflurane had little effect on enzymatical system of mitochondrial electron transfer chain. These data indicate that halothane interfere with utilization of NADH-linked substrate by blocking electon transport from NADH to cytochrome C and it is probable that the locus of action is at Q binding protein(Qpn) or complex of Qpn and ubiquinone.

Hepatic histopathological studies of hepatotoxicity of halothane vs sevoflurane in enzyme- induced hypoxic rats / 中华麻醉学杂志

Male Sprague~Dawley rats were pretreated with phenobarbital and randomly divided into 6 groups and were exposed to O2,/N2/l. 2 MAC anesthetics for I hr; NC, 21 % O2/79% N2; HC, 14 %O2,/86%N2; NH, 21 %O2/79% N2/l. 2 MAC halothane;HH, 14 %O2/86 %N2/ 1. 2 MAC Halothane; NS, 21 %O2/79%N2/ 1. 2 MAC sevoflurane; HS, 14 %O2/86 %N2/ 1. 2 MAC sevoflurnae. Liver specimens andblood were taken 24 hrs after exposure. Thenecrosls and denaturatlon of hepatocellularwere quantltatlvely estlmated by stereoscopy.Ultrastructural morphology was analysed by computer. The liver ofall rats given halothane (14%O2) had extensive centrilobu- lar necrosls and denaltlration. There were an increase in serum glutamic pyruvic transmi- nase accompnaying the morphologic damage。No marked hepatotoxicity was foundin the rats following sevoflurane expoure compared with controls. Hypoxia was the main cause of swelling of mltochondria. Results suggest that sevoflurane has less hepattc injtry than holotnane.

A comparison of biotransformation of volatile anesthetics during moderate length operation / 대한마취과학회지

The halogenated anesthetics, halothane, enflurane and isoflurane undergo biotransformation in man. They produce inorganic fluoride ion as a metabolite, which is well known as the cause of methoxyflurane induced nephrotoxicity. This study was done to investigate the rapidity and extent of biotransformation of volatile anesthetics for 2 hours of operation. Thirty patients were randomly divided into halothane, enflurane and isoflurane group according to anesthetics. Blood and urine sampling was done before operation, post-induction 10 min, 20 min, 30 min, 1 hour, 1 hour 30 min and 2 hours for the measurement of inorganic fluoride ion. Aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen and creatinine levels were measured before and 24 hours after operation. The results were as follows ; 1) The values of blood fluoride ion in halothane and isoflurane group were decreased with time during operation and there was no change in enflurane group. 2) The values of urine fluoride ion in three groups were increased with time during operation. The rate of increase was the greatest in enflurane group. 3) There were no changes in the value of AST, ALT, BUN and creatinine. The above results suggest that the biotransformation of volatile anesthetics to inorganic fluoride ion was the greatest in enflurane, but the level was insufficent to cause renal dysfunction during 3.18 hour operation.

SARAcap Monitoring of End - Tidal Volatile Anesthetics during Anesthesia / 대한마취과학회지

Thirty (19-58yr) patients received halothane, enflurane and isoflurane with Ohmeda, Cyprane and Narcomed vaporizer for maintenance of anesthesia during controlled ventilation. End-tidal fractional concentrations(FE) of the volatile anesthetic agents were measured for 40 minutes after induction. Inspired oxygen fractional concentrations during anesthesia in the three groups were slightly decreased from minimal 33.1+/-2.3% to maximal 49.3+/-1.7%. End-tidal carbon dioxide concentrations during anesthesia in the three groups were within normal lirnit ranged from minimal 24.5+/-3.2 mmHg to maximal 35.2+/-3.4 mrnHg. When vaporizer's dial was fixed at 1% halothane, average measured FE/FI ratio were gradually increased from 5 minutes to 40 minute in the three groups. But FE/FI ratios were lower than dial setting, except after 40 minutes in the Narcomed vaporizer. When vaporizer's dial were fixed at 1% isoflurane and enflurane, average measured FE/PI ratios in the three groups were nearly equal but lower than dial setting. These results suggest that the actual gas concentrations of used(2-3yr) vaporizers were measured slightly lower than dial setting and we need to continuously monitoring of respiratory gas and end-tidal anesthetic gases.

Comparison of Uptake and Elimination of Volatile Anesthetics / 대한마취과학회지

To compare the rate of uptake and elimination of volatile anesthetics, we administered 2% Halothane, 2% Enflurane and 2% Isoflurane respectively for one hour to 90 healthy adult patients through a semicolsed circuit with controlled ventilation to maintain normocapnea for determining the rates of uptake, and the volatile anesthetics and nitrous oxide were discontinued to determine the rates of elimination for 30 minutes. The expired(Fe=Fa) and inspired(F1) vapor concentrations of volatile anethetics were measured using an infrared analyser and F(A)/ F(1) ratios were used to determine rates of uptake, and F(A)/F(AO)(Where F(AO) is the last end-tidal concentration during uptake) ratios were used to determine rates of elimination. And to evaluate the effects of gas flow pattern on the rate of uptake and elimination, the patients were divided into three groups: Control group inhaled three volatile anesthetics respectively with 3 liter of oxygen per minute, study group 1 inhaled three volatile anesthetics respectively with 6 liter of oxygen per minute and study group 2 inhaled three volatile anesthet- ics respectively with 1 liter of oxygen and 2 liter of nitrous oxide. The results obtained were as follows: l) To compare the rate of uptake(F(A)/F(1)) of the anesthetics, the pulmonary uptake was most rapid with isoflurane followed by enflurane and halothane in accord with their respective solubilities in blood 2) With increased fresh gas flow, the rates of uptake of anesthetics more rapidly augmented, especially significantly in halothane and enflurane 3) With gas mixture of 70% N2O, the rate of uptake of anesthetics more rapidly augmented, especially significantly in isoflurane and enflurane 4) To compare the rate of elimination of anesthetics, isoflurane and enflurane eliminated more rapidly than halothane but there are no difference in that of isoflurane with enflurane in control group. But there are no difference significantly between that of halothane, enflurane and isoflurane in study group 1 and 2. 5) With increased gas flow rate, the rate of elimination decreased more rapidly in halothane, enflurane and isoflurane significantly. 6) By the elimination of anesthetics with N2O simultaneously from the lung, the rate of elimination decreased more rapidly in halothane and isoflurane significantly. In conclusion, we have shown that we can obtained more rapid induction and recovery of inhalation anesthetics with lower solubility of anesthetics. In addition, with increased fresh gas flow and use of gas mixture af nitrous oxide, induction and recovery of anesthetics will be more rapidly.