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GENERAL ARTICLES

Exposure to Sevoflurane and Nitrous Oxide During Four Different Methods of Anesthetic Induction

Klaus H. Hoerauf, MD^*, Thomas Wallner, MD, Ozan Akça, MD^,, Reza Taslimi, MD, and Daniel I. Sessler, MD^,,§,||

Departments of Anesthesia and General Intensive Care ( *B) and ( A), Outcomes Research^TM, and §Ludwig Boltzmann Institute for Clinical Anesthesia and Intensive Care, University of Vienna, Vienna, Austria; and ||Department of Anesthesia, University of California San Francisco, San Francisco, California

Address correspondence to Dr. Klaus Hoerauf, Department of Anesthesia and General Intensive Care (B), University of Vienna, Währinger-Gürtel 18–20, A-1090 Vienna, Austria. Address e-mail to klaus.hoerauf{at}univie.ac.at

The National Institute for Occupational Safety and Health-recommended exposure levels for nitrous oxide exposure are 25 ppm as a time-weighted average over the time of exposure. The exposure limit for halogenated anesthetics (without concomitant nitrous oxide exposure) is 2 ppm. Inhaled sevoflurane provides an alternative to IV induction of anesthesia. However, the inadvertent release of anesthetic gases into the room is likely to be greater than that with induction involving IV anesthetics. We therefore evaluated anesthesiologist exposure during four different induction techniques. Eighty patients were assigned to one of the induction groups to receive: 1) sevoflurane and nitrous oxide from a rebreathing bag, 2) sevoflurane and nitrous oxide from a circle circuit, 3) propofol 3 mg/kg, and 4) thiopental sodium 5 mg/kg. Anesthesia was maintained with sevoflurane and nitrous oxide via a laryngeal mask. Trace concentrations were measured directly from the breathing zone of the anesthesiologist. During induction, peak concentrations of sevoflurane and nitrous oxide with the two IV methods rarely exceeded 2 ppm sevoflurane and 50 ppm nitrous oxide. Concentrations during the two inhalation methods were generally <20 ppm sevoflurane and 100 ppm nitrous oxide. During maintenance, median values were near 2 ppm sevoflurane and 50 ppm nitrous oxide in all groups. Sevoflurane concentrations during inhaled induction frequently exceeded the National Institute for Occupational Safety and Health-recommended exposure ceiling of 2 ppm but mostly remained <20 ppm. Exposure during the maintenance phase of anesthesia also frequently exceeded the 2-ppm ceiling. We conclude that operating room anesthetic vapor concentrations are increased during inhaled inductions and remain increased with laryngeal mask ventilation.

Implications: We compared waste gas concentrations to sevoflurane and nitrous oxide during four different induction methods. During inhaled induction with a rebreathing bag or a circle circuit system, waste gas concentrations frequently exceed National Institute for Occupational Safety and Health limits of 2 ppm sevoflurane and 50 ppm nitrous oxide. Therefore, we recommend that people at risk (e.g., women of child-bearing age) should pay great attention when using this technique.

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