Ambulatory Anesthesiology

Peter S. A. Glass

Desflurane Versus Sevoflurane for Maintenance of

Outpatient Anesthesia: The Effect on Early Versus Late
Recovery and Perioperative Coughing
Paul F. White, PhD, MD, BACKGROUND: There is controversy regarding the relative perioperative benefits of
FANZCA* desflurane versus sevoflurane when used for maintenance of anesthesia in the
ambulatory setting. Although studies have consistently demonstrated a faster emer-
Jun Tang, MD gence with desflurane (versus sevoflurane), the impact of this difference on the later
recovery end points has not been definitively established. Furthermore, the effect of
desflurane (versus sevoflurane) on the incidence of coughing is also controversial.
Ronald H. Wender, MD METHODS: We randomized 130 outpatients undergoing superficial surgical procedures
requiring general anesthesia to one of two maintenance anesthetic treatment groups.
Roya Yumul, MD, PhD All patients were induced with propofol, 2 mg/kg IV, and after placement of a
laryngeal mask airway, anesthesia was maintained with either sevoflurane 1%3% or
O. Jameson Stokes, MS, MD desflurane 3% 8% in an air/oxygen mixture. The inspired concentration of the volatile
anesthetic was varied to maintain hemodynamic stability and a Bispectral Index value
Alexander Sloninsky, MD of 50 60. Analgesia was provided with local anesthetic infiltration and ketorolac (30
mg IV). Antiemetic prophylaxis consisted of a combination of ondansetron (4 mg),
Robert Naruse, MD dexamethasone (4 mg), and metoclopramide (10 mg) at the end of surgery. Assessments
included recovery times to eye opening, response to commands, orientation, fast-track
score of 14, first oral intake, sitting, standing, ambulating unassisted, and actual discharge.
Robert Kariger, MD Patient satisfaction with anesthesia, the ability to resume normal activities on the first
postoperative day, adverse side effects (e.g., coughing, purposeful movement, oxygen
Evelyn Norel, MD desaturation 90%, sore throat, postoperative nausea, and vomiting), and the requirement
for postoperative analgesic and antiemetic drugs were recorded in the early postoperative
Steven Mandel, MD period and during the initial 24-h period after discharge.
RESULTS: The two study groups had comparable demographic characteristics. Although
Tom Webb, MD the overall incidence of coughing during the perioperative period was higher in the
desflurane group (60% versus 32% in the sevoflurane group, P 0.05), the incidences of
Alan Zaentz, MD coughing during the actual administration of the volatile anesthetics (i.e., the maintenance
period) did not differ between the two groups. Emergence from anesthesia was more rapid
after desflurane; however, all patients achieved fast-track recovery criteria (fast-track score
12) before leaving the operating room. Finally, the time to discharge home (90 31 min
in sevoflurane and 98 35 min in desflurane, respectively) and the percentage of patients
able to resume normal activities on the first postoperative day (sevoflurane 48% and
desflurane 60%) did not differ significantly between the two anesthetic groups.
CONCLUSIONS: Use of desflurane for maintenance of anesthesia was associated with a
faster emergence and a higher incidence of coughing. Despite the faster initial recovery
with desflurane, no significant differences were found between the two volatile
anesthetics in the later recovery period. Both volatile anesthetics should be available for
ambulatory anesthesia.
(Anesth Analg 2009;109:38793)

I n providing general anesthesia for ambulatory sur-

gery, the goal is to achieve optimal surgical conditions
while ensuring a rapid early recovery without side
effects. However, increasing attention is being focused
From the *Department of Anesthesiology and Pain Manage-
ment, University of Texas Southwestern Medical Center at Dallas,
Dallas, Texas; and Department of Anesthesiology, Cedars-Sinai
Medical Center, Los Angeles, California.
Accepted for publication April 5, 2009.
Supported in part by an educational grant from Baxter Health-
care, the manufacturer of desflurane (Suprane) and sevoflurane, to
the White Mountain Institute, a non-for-profit private educational
and research foundation (Dr. PFW, President). Dr. Whites salary is
supported in part by endowment funds from the Margaret Milam
McDermott Distinguished Chair in Anesthesiology.
on pharmacoeconomic issues (e.g., relative cost of
volatile anesthetic drugs) and the role of anesthetic
The primary author (Dr. PFW) has received educational grants
for designing investigator-initiated studies with Baxter products
(e.g., desflurane, propofol, esmolol, and transdermal scopolamine).
Paul F. White is Section Editor of Book, Multimedia and Meeting
Reviews for the Journal. This manuscript was handled by Peter S. A.
Glass, Section Editor of Ambulatory Anesthesiology, and Dr. White
was not involved in any way with the editorial process or decision.
Address correspondence and reprint requests to Dr. P. F. White,
Department of Anesthesiology and Pain Management, University of
Texas Southwestern Medical Center, 5323 Harry Hines Blvd., F2.208,
Dallas, TX 75390-9068. Address e-mail to paul.white@utsouthwestern.edu.
Copyright 2009 International Anesthesia Research Society
DOI: 10.1213/ane.0b013e3181adc21a

Vol. 109, No. 2, August 2009 387

drugs in facilitating a fast-track recovery in order for
patients to resume their normal activities of daily
living more rapidly after surgery.1 Both desflurane
(Suprane) and sevoflurane are currently in widespread
clinical use for maintenance of anesthesia in the ambu-
latory setting.
In an effort to reduce anesthesia-related costs, some
institutions have questioned the need to have both
volatile anesthetics in their ambulatory facilities. Al-
though studies have consistently reported a faster early
recovery (i.e., emergence) with desflurane compared
with sevoflurane, the impact of these volatile anesthetics
on later recovery end points remains controversial.27
Song et al.2 reported that a higher percentage of patients
receiving desflurane for maintenance of anesthesia were
fast-track eligible (90% vs 75% for sevoflurane); how-
ever, later recovery times in that ambulatory surgery
population were similar for the two volatile anesthetics.
In a more recent report, Mahmoud et al.3 reported that
the use of desflurane for minor outpatient gynecological
surgery resulted not only in a faster emergence but also
facilitated recovery of normal activity on the first post-
operative day when compared with sevoflurane. How-
ever, the latter observation was not supported by the
findings of other investigative groups.4 7 The concomi-
tant administration of centrally active adjuvant drugs
(e.g., benzodiazepines, opioid analgesics, and nitrous
oxide), as well as muscle relaxant and reversal drugs,
might explain the differences in these comparative stud-
ies. Furthermore, controversy also surrounds the relative
incidence of coughing when these two volatile anesthe-
tics are used for maintenance of anesthesia in combina-
tion with a laryngeal mask airway (LMA) device.
Therefore, we designed a prospective, randomized
study to evaluate the hypothesis that the use of desflu-
rane (versus sevoflurane) for maintenance of anesthesia
would result in a higher percentage of patients resuming
normal activities of daily living on the first day after
ambulatory surgery. The secondary objective of this
study was to assess the effect of the volatile anesthetic on
the incidence of coughing during and immediately after
surgery.
METHODS
After obtaining IRB approval at Cedars Sinai Medical
Center in Los Angeles and written informed consent, 130
patients scheduled for superficial (noncavitary) surgical
procedures (e.g., hernia repair, partial mastectomy, or
resection of lipomas) were enrolled in this prospective
study. Patients were randomly assigned to one of the
two anesthetic treatment groups according to a
computer-generated random numbers table. Pa-
tients received either sevoflurane or desflurane for
maintenance of anesthesia. Exclusion criteria included
pregnancy, obesity (defined as a body mass index
30), a history of gastroesophageal reflux (or hiatal
hernia), clinically significant cardiovascular, hepato-
renal, pulmonary, neurologic, metabolic, or endocrine
388 Desflurane versus Sevoflurane in Ambulatory Anesthesia
disorders, or a recent (6 mo) history of alcohol or
drug abuse.
Patients were asked to provide a detailed medical
history and demographic information, including age,
weight, height, alcohol or drug consumption, and
history of smoking, postoperative nausea and vomit-
ing (PONV), or motion sickness, and ability to per-
form normal physical activities of daily living. Before
entering the operating room (OR), patients completed
baseline verbal rating scales (VRS) for pain and nau-
sea, with 0 none to 10 severe. On arrival in the
OR, standard monitoring devices and the electroen-
cephalographic Bispectral Index (BIS) monitor were
applied. The inspired and end-tidal concentrations of
sevoflurane and desflurane were monitored con-
tinuously with a calibrated infrared gas analyzer.
Hemodynamic and anesthetic variables were recorded
before anesthetic administration, at 2-min intervals
from induction of anesthesia until 10 min after skin
incision and, subsequently, at 5-min intervals until the
end of the surgical procedure. All episodes of cough-
ing after induction of anesthesia until the patient was
awake and oriented were recorded by a blinded
observer (OJS).
Patients received no preanesthetic medication, intra-
operative opioid analgesics, or muscle relaxant drugs.
Anesthesia was induced with propofol (2 mg/kg IV)
after 2 mL of 1% lidocaine IV was administered to
minimize propofol-induced injection pain. After an
LMA was inserted, study patients were randomized to
receive either sevoflurane 2%3% inspired or desflu-
rane 6% 8% inspired in a 50:50 air/oxygen mixture
for initial maintenance of anesthesia at a total gas flow
rate of 3 L/min. The inspired concentrations of
sevoflurane or desflurane were subsequently adjusted
to maintain a clinically acceptable depth of anesthe-
sia (i.e., providing good surgical conditions while
maintaining a stable spontaneous respiratory rate,
mean arterial blood pressure and heart rate values
within 20% of the preinduction baseline values, and a
BIS value of 50 60). Before the end of surgery, ondan-
setron (4 mg IV), dexamethasone (4 mg IV), and
metoclopramide (10 mg IV) were administered to all
patients for antiemetic prophylaxis. Preventative an-
algesia was provided using ketorolac (30 mg IV;
before the end of surgery) and a local anesthetic
solution containing a 1:1 mixture of 2% lidocaine and
0.5% bupivacaine was injected at the surgical incision
site before the skin incision and again at the time of
closure. The maintenance anesthetics were discontin-
ued after closure of the surgical wound. On awaken-
ing from anesthesia (i.e., eye opening), the LMA
device was removed, and patients were assessed at
1-min intervals to determine their ability to meet
specific fast-track criteria.8 Immediately after the ap-
plication of the surgical dressing, patients were trans-
ferred to the day-surgery recovery area.
Anesthesia time (from induction of anesthesia to
discontinuation of sevoflurane or desflurane) and
ANESTHESIA & ANALGESIA
surgery time (from skin incision to placement of the Table 1. Demographic Characteristics, Duration of Anesthesia
dressing) were noted. Surgeons were asked to evalu- and Surgery, Dosage of Anesthetics, Adjunctive Local
ate the operating conditions after skin closure using a Anesthetics and Analgesic During Recovery Room Between the
Two Study Groupsa
3-point VRS: 2 highly satisfied, 1 satisfied, and
0 dissatisfied. The assessment of recovery times for Sevoflurane Desflurane
determining when patients were able to open their Number (n) 65 65
eyes, follow commands (e.g., squeeze the investiga- Age (yr) 43 14 44 14
tors hand), and were oriented to their name and Weight (kg) 71 10 73 12
place/date of birth was assessed by the blinded Height (cm) 167 10 165 11
Sex (male/female) (n) 28/37 30/35
observer at 1-min intervals on discontinuing the vola- ASA physical status (I/II/III) 24/31/10 22/33/10
tile anesthetics. The times to sitting, standing, ambu- (n)
lating without assistance, and tolerating oral fluids Previous PONV (yes/no) (n) 13/52 9/56
were assessed at 10-min intervals in the recovery room Previous motion sickness 10/55 13/52
before discharge home. The duration of the recovery (yes/no) (n)
History of smoking (yes/no) (n) 11/54 15/50
(i.e., postanesthesia care unit [PACU]) stay and time to Baseline verbal rating
actual discharge were also recorded from the end of scale scores (010)
anesthesia (i.e., discontinuation of the volatile anes- Nausea 0 (00) 0 (00)
thetics). The discharge criteria required that the pa- Pain at rest 0 (01) 0 (00)
tients be awake and alert with stable vital signs, able Able to perform normal 65 (100) 65 (100)
activities before surgery,
to ambulate without assistance, and not be experienc- n (%)
ing any acute side effects (e.g., nausea or vomiting) or Type of surgery (n)
moderate-to-severe pain.8 Inguinal hernia repair 23 24
Pain and nausea were assessed at 30-min intervals Partial mastectomy 34 30
in the recovery area and at the time of discharge home Lipoma resection 8 11
Anesthesia time (min) 39 14 45 23
using the standard 11-point VRS. Side effects (e.g., Surgery time (min) 34 16 38 19
PONV, dizziness, and confusion) were recorded by Propofol dosage (mg) 183 30 186 31
the recovery room nurses, as well as the need for any End-tidal volatile during 1.3 0.4 4.8 1.9
rescue medications. The rescue medication for PONV surgery (%)
was phenergan (12.5 mg IV/IM) and for complaints of Local anesthetics (2% lidocaine 34 12 33 12
0.5% bupivacaine) (mL)
surgical-related pain, oral hydrocodone/acetami- Oral opioid analgesics required 13 (20) 12 (18)
nophen was administered. A trained interviewer who in recovery room, n (%)
was also blinded to the study group contacted the PONV postoperative nausea and vomiting.
patients by telephone at home 24 h after discharge to a
Values are means SD, numbers (n), medians (interquartile ranges), or percentages (%).
inquire about postdischarge side effects (e.g., emetic
symptoms, fatigue, and wound complications) and the
need for any therapeutic interventions. The patients using the 2 test or Fishers exact test where appropri-
were also asked to rate their overall satisfaction with ate. A P value of 0.05 was considered statistically
the anesthetic experience on a 3-point rating scale: 2 significant. Data are presented as mean values sd,
highly satisfied, 1 satisfied, or 0 dissatisfied. or median values (with interquartile ranges), numbers
Finally, the ability of patients to resume their normal (n), and percentages (%).
activities of daily living (e.g., normal gastrointestinal
function, household activities, and ability to take short
trips outside the home to go shopping or return to RESULTS
work) within the 24-h follow-up period was deter- One hundred thirty patients were able to successfully
mined based on the telephone interview.9,10 complete all the assessments required for this prospec-
tive randomized study. The two study treatment groups
Statistical Analysis were comparable with respect to demographic charac-
An a priori power analysis suggested that group teristics (Table 1). Based on the assumption that the
sizes of 65 should be adequate to detect a significant anesthetic minimum alveolar anesthetic concentration
difference (25%) in the percentage of patients able to (MAC) values for sevoflurane and desflurane in this
resume their normal activities of daily living on the patient population were 1.8% and 6%, respectively,
first postoperative day based on the previous findings the average end-tidal concentrations of the inhaled
by Mahmoud et al.3 where 77% and 52% of the anesthetics during the maintenance period were 0.72
patients receiving desflurane and sevoflurane, respec- of the MAC for sevoflurane and 0.8 of the MAC for
tively, achieved this end point, with an 0.05 and desflurane. These MAC multiples did not differ sig-
0.80. Normally distributed continuous data nificantly between the two treatment groups (P
were analyzed using Students t-test. Continuous 0.05). The durations of anesthesia and surgery, the
data not normally distributed were analyzed using a volume and concentration of local anesthetic solution
MannWhitney U-test. Categorical data were analyzed injected during the perioperative period, and the

Vol. 109, No. 2, August 2009 2009 International Anesthesia Research Society 389
Table 2. Recovery Times After the End of Anesthesia and the Table 3. Side Effects Between the Two Study Groups During the
Patients Satisfaction with Anesthesia Experience Between the Study Perioda
Two Study Groupsa
Sevoflurane Desflurane
Sevoflurane Desflurane Number (n) 65 65
Eye opening (min) 85 5 3* PONV before discharge, n (%)
Responds to commands (min) 94 6 2* Nausea 11 (17) 9 (14)
Orientation (min) 11 6 8 4* Vomiting 5 (8) 3 (5)
Fast-tracking score upon 13 (1214) 14 (1314) Rescue 5 (3) 4 (6)
leaving operating room PONV after discharge, n (%)
(014) Nausea 23 (35) 20 (31)
Sitting (min) 35 16 32 10 Vomiting 0 (0) 2 (3)
First oral fluids (min) 47 21 50 24 Rescue 0 (0) 0 (0)
Standing (min) 69 25 71 28 Movement during the 20 (31) 24 (37)
Ambulate unassisted (min) 72 29 77 24 operation, n (%)
Recovery room stay (min) 79 33 80 34 Incidences of coughing, n (%)
Hospital discharge (min) 90 31 98 35 During the induction 3 (5) 6 (9)
Patient satisfaction period
with anesthesia, n (%) During the intraoperative 3 (5) 5 (8)
Highly satisfied 62 (95) 63 (97) period
Satisfied 3 (5) 2 (3) During the emergence period 4 (6) 10 (15)
Surgeon satisfaction with During the perioperative 10 (15) 21 (32)*
operating conditions, (overall) period
n (%) Patients who coughed both 2 4
Highly satisfied 64 (98) 62 (95) during surgery and on
Satisfied 1 (2) 3 (5) emergence from anesthesia
Resume normal activity 31 (48) 39 (60) (n)
on first postoperative day, Confusion on emergence, n (%) 2 (3) 3 (5)
n (%) Shivering in PACU, n (%) 3 (5) 3 (5)
Recovery variables in patients n 10 n 21 Dizziness in PACU, n (%) 3 (5) 2 (3)
who coughed PONV postoperative nausea and vomiting; PACU postanesthesia care unit.
Hospital discharge time 93 35 98 35 a
Values are number (n) or percentages (%).
(min) * P 0.05 versus sevoflurane group.
Resumed normal activities 4 (40) 12 (57)
on first postoperative
day, n (%) anesthesia were nonsignificantly higher in patients
a
Values are means SD, median (interquartile range), number (n), or percentages (%). receiving desflurane; however, the overall (combined)
* P 0.05 versus sevoflurane group.
incidence of coughing during the perioperative period
was significantly higher in the desflurane (versus
number of oral opioid-containing analgesics adminis- sevoflurane) group (P 0.05; Table 3). The coughing
tered in the recovery area were also similar in the two episodes that occurred were short lasting, did not lead
anesthetic groups (Table 1). In addition, the intraop- to laryngospasm (or decreases in oxygen saturation
erative hemodynamic variables did not differ between 90%), or interrupt the surgical procedures. There
the two groups (data not reported). were no differences in the length of the recovery stay
Early recovery end points, including time to eye (98 35 min vs 93 35 min) or the ability to resume
opening, following commands, and orientation, were normal activities on the first postoperative day (57%
significantly shorter in the desflurane (versus sevoflu- vs 40%) in those patients who coughed during the
rane) group (Table 2). However, all patients met perioperative period in the desflurane (n 21) and
fast-track recovery criteria (fast track score 12) upon sevoflurane (n 10) groups, respectively. Although
leaving the OR. There was no significant difference minor movements were observed in 37% and 31% of
between the two groups with respect to the times to the patients in the desflurane and sevoflurane groups,
sitting, tolerating fluids, standing, or ambulating respectively, none of the surgeons reported being dissat-
alone. In addition, the length of PACU stay and the isfied with the operating conditions. Finally, there was
times to actual discharge home did not differ between no significant difference in the incidences of postopera-
the two groups. Although a higher percentage of tive sore throats, surgical-related pain, nausea, or emesis
patients in the desflurane group (60%) reported re- between the two volatile anesthetic treatment groups.
suming normal activities of daily living on postopera-
tive day one compared with the sevoflurane group DISCUSSION
(48%), this difference failed to achieve statistical sig- Desflurane offered an advantage over sevoflurane
nificance (P 0.16). Of importance, 95%97% of the with respect to early recovery end points (i.e., emer-
patients in both groups were highly satisfied with gence from anesthesia). However, the intermediate
their overall anesthesia experience (Table 2). (before discharge home) and later recovery (within
The incidences of coughing during induction of 24 h after discharge) end points did not differ signifi-
anesthesia, intraoperatively, or at emergence from cantly between the two anesthetic groups. Therefore,

390 Desflurane versus Sevoflurane in Ambulatory Anesthesia ANESTHESIA & ANALGESIA

the results of this study do not fully support the earlier
study by Mahmoud et al.,3 reporting that the faster
emergence after discontinuation of desflurane led to
an earlier discharge and more rapid resumption of
normal activities compared with sevoflurane. How-
ever, we studied a more heterogenous ambulatory
surgery population undergoing a wide variety of
superficial surgical procedures, including both male
and female outpatients. The current findings are con-
sistent with previously published comparative studies
demonstrating that the faster emergence from desflu-
rane (versus sevoflurane) anesthesia failed to lead to
an earlier discharge from PACU or hospital after both
outpatient2,5 and inpatient4,6,7 surgical procedures re-
gardless of whether a tracheal tube or a LMA was
used for airway management.1113 In contrast to the
previous studies,4 7,14 these data suggest that desflu-
rane may well have facilitated an earlier resumption of
normal activities after these outpatient surgical proce-
dures if we had studied a larger patient population
(i.e., group sizes of 269 patients each) and adminis-
tered equipotent concentrations of the two volatile
anesthetics.
As a result of the lower solubility of desflurane
(versus sevoflurane) in blood and lean tissues, one
might expect to find differences in the intermedi-
ate and late recovery end points when these two
anesthetics are used for longer surgical procedures.
However, most studies4,6,7 have found that only early
recovery was more rapid after desflurane (versus
sevoflurane), even when the duration of surgery ex-
ceeded 2 h. Furthermore, the recovery of psychomotor
and cognitive function after desflurane and sevoflu-
rane were similar after the first 30 45 min in both
younger patients undergoing ambulatory surgery5
and elderly patients undergoing more prolonged gen-
eral anesthesia for inpatient procedures.6,7 Even when
used for maintenance of anesthesia in morbidly obese
patients, desflurane produced similar intermediate
and late recovery profiles compared with sevoflu-
rane.4 In a meta-analysis15 in which the duration of
anesthesia was up to 3 h, investigators found that
times to following commands, tracheal extubation,
and orientation were only 1.0 1.2 min shorter in
patients receiving desflurane compared with sevoflu-
rane, and there were no significant differences in the
length of stay in the PACU or the ambulatory surgical
facility.
One explanation for the controversy regarding the
comparative recovery characteristics of these two
popular volatile anesthetics could be the potentially
confounding effects of adjunctive drugs administered
in the previously mentioned studies. The residual
effects of benzodiazepines, opioid analgesics, and
muscle relaxants can alter the recovery characteristics
of the volatile anesthetics. In our study, none of the
patients received these adjuvants during the periop-
erative period. Furthermore, the average end-tidal
concentrations of desflurane and sevoflurane were
Vol. 109, No. 2, August 2009
4.8% 1.9% and 1.3% 0.4%, respectively, during the
operation, and 3.1% 0.9% and 1.1% 0.4%, respec-
tively, at the end of anesthesia. Therefore, the patients
recovery profiles were compared following approxi-
mately equipotent concentrations (0.72 vs 0.8 MAC h)
of the two volatile anesthetics. Use of the BIS monitor
as a guide for titrating the volatile anesthetic has been
demonstrated to facilitate the fast-tracking process
after surgical procedures.14 In the current study, it can
be concluded that maintaining the BIS value between
50 and 60, as well as the avoidance of benzodiaz-
epines, opioid analgesics, and muscle relaxants, al-
lowed all the patients to achieve the fast-track criteria8
when they were transferred out of the OR. Further-
more, all patients were discharged home within 2 h
after the end of the operation.
Because of the greater pungency and airway irritant
properties of desflurane,16 sevoflurane has been called
the ideal agent for adult day-case anesthesia.17
Previous studies comparing desflurane and sevoflu-
rane when administered for minor outpatient surgical
procedures using an LMA for airway management
have reported a low incidence of respiratory compli-
cations and no significant differences between the two
volatile anesthetics.3,1113 Analogous to our findings,
Klock et al.18 reported that at 1 MAC, sevoflurane was
superior to desflurane for suppression of clinically
relevant cough responses to tracheal stimulation.
However, at deeper levels of anesthesia (e.g., 1.8
MAC), sevoflurane and desflurane both suppressed
the cough response to tracheal stimulation.18 In an-
other airway response study involving the use of these
two volatile anesthetics with a LMA device, Arain et
al.19 reported that the airway responses at 1 MAC of
desflurane and sevoflurane were negligible and did
not significantly differ between the two anesthetics.
However, the incidences of coughing and breath hold-
ing were significantly higher in the desflurane group
(versus sevoflurane) as the volatile anesthetic concen-
tration increased to 2 MAC.19 A more recent study by
McKay et al.12 suggested that cigarette smoking, not
use of desflurane or sevoflurane, increased patients
risk of coughing and respiratory complications. How-
ever, the number of smokers did not differ signifi-
cantly between the two volatile anesthetic groups (11
and 15 in the sevoflurane and desflurane groups,
respectively) in this study.
It is possible that the use of fentanyl during the
intraoperative period may have minimized the differ-
ence between the airway responses to desflurane and
sevoflurane in some of the previous studies.3,11,13,19,20
In this study, no opioid analgesics were administered,
and the overall incidence of coughing was signifi-
cantly higher in patients receiving desflurane (versus
sevoflurane) despite the use of lower anesthetic con-
centrations (1 MAC) of the volatile anesthetics. Both
the volatile anesthetic groups included both smokers
and nonsmokers. Unfortunately, because of the rela-
tively small number of smokers in our study, we could
2009 International Anesthesia Research Society 391
not perform a subset analysis to determine whether
smoking would have an independent effect on this
outcome variable. The higher incidence of airway
reactivity during the emergence period with desflu-
rane was consistent with results from one of the
previous studies.19 This finding may be explained by
the fact that desflurane allows an earlier return of
protective airway reflexes during the emergence pe-
riod when compared with sevoflurane.21 The rigid
timing of the removal of the LMA device after discon-
tinuation of the volatile anesthetic may have been a
contributing factor to the occurrence of coughing on
emergence from anesthesia. To reduce the risk of
coughing after desflurane, many practitioners recom-
mend that the LMA device be removed upon discon-
tinuation of the volatile anesthetic.
In an earlier study with a similar anesthetic regi-
men,22 17%35% of the patients manifested one or
more purposeful movements during the operation in
response to a surgical stimulus. In the current study,
31%37% of these nonparalyzed, spontaneously breath-
ing patients experienced a transient motor response
during the operation. Importantly, these minor move-
ments during surgery did not interfere (or interrupt)
with the conduct of the operation, and none of the
surgeons expressed dissatisfaction with either of the
anesthetic techniques. The avoidance of opioid anal-
gesics and neuromuscular reversal drugs, as well as
the routine administration of three prophylactic anti-
emetics during surgery, minimized the risk of PONV
in this outpatient surgery population.
An important criticism of this study relates to the
possibility of bias as a result of the fact that the
anesthesiologist administering the volatile anesthetic
was not blinded. The anesthesiologists were in-
structed to maintain a minimally acceptable depth of
anesthesia (i.e., to prevent purposeful movement and
maintain hemodynamic and respiratory stability
while attempting to achieve a rapid emergence from
anesthesia). The BIS values were maintained in the
50 60 range with both volatile anesthetics until the
end of the operation.14 Importantly, all the evaluations
during the perioperative period were conducted by a
blinded investigator. In an attempt to minimize vari-
ability, all volatile anesthetics were discontinued on
completion of the skin closure rather than at variable
times before the end of the surgery. Another criticism
of this study may relate to a lack of adequate power to
detect differences in the primary outcome variable. On
the basis of the current findings, a minimum of 269
patients in each volatile anesthetic group would be
required to achieve a statistically significant difference
based on the percentages of patients returning to
normal activities of daily living on the first postopera-
tive day in this outpatient surgery population. It is
possible that the failure to find a difference in the
primary outcome variable was also influenced by the
fact that patients in the desflurane group received a
nonsignificantly higher concentration of the volatile
392 Desflurane versus Sevoflurane in Ambulatory Anesthesia
anesthetic during the maintenance period (0.8 MAC vs
0.72 MAC for sevoflurane, P 0.076).
In conclusion, maintenance of anesthesia with ei-
ther desflurane or sevoflurane allowed for a fast-track
recovery after these superficial ambulatory surgery
procedures. The faster emergence displayed by pa-
tients in the desflurane group failed to result in a
significantly more rapid resumption of normal activi-
ties of daily living when compared with sevoflurane.
However, 60% of the desflurane-treated patients were
able to resume their normal activities on the first
postoperative day after surgery compared with less
than half of the patients in the sevoflurane group.
Finally, the incidences of coughing were similar with
both volatile anesthetics during the maintenance pe-
riod; however, the desflurane group experienced a
higher overall incidence of coughing during the entire
perioperative period. We conclude that both of these
popular volatile anesthetics should be available to
clinicians for use in ambulatory anesthesia.
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