Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Original Investigation

Minimal fresh gas flow sevoflurane anesthesia and postoperative acute kidney injury in on-pump cardiac surgery: a randomized comparative trial

Eric Benedet Lineburger, Norma Sueli Pinheiro Módolo, Leandro Gobbo Braz, Paulo do Nascimento Junior

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: Compound A is generated by sevoflurane when it reacts with carbon dioxide absorbers with strong bases at minimal fresh gas flow (FGF) and is nephrotoxic in animals. No conclusive data has shown increased risk in humans. The aim of this study was to investigate if minimal FGF promotes an increase in the incidence of acute kidney injury (AKI) when compared to high FGF in patients undergoing on-pump cardiac surgery under sevoflurane anesthesia.

: Two hundred and four adult patients scheduled for on-pump cardiac surgery under sevoflurane anesthesia were randomly allocated to two groups differentiated by FGF: minimal FGF (0.5 L.min−1) or high FGF (2.0 L.min−1). Baseline creatinine measured before surgery was compared daily to values assayed on the first five postoperative days, and 24-hour urinary output was monitored, according to the KDIGO (Kidney Disease Improving Global Outcomes) guideline to define postoperative cardiac surgery-associated acute kidney injury (CSA-AKI). Creatinine measurements were also obtained 20 and 120 days after hospital discharge.

: Postoperative AKI occurred in 55 patients, 26 patients (29.5%) in the minimal FGF group and 29 patients (31.5%) in the high FGF group (p = 0.774). Twenty days after discharge, 11 patients (6.1%) still had CSA-AKI and 120 days after discharge only 2 patients (1.6%) still had CSA-AKI.

: When compared to high FGF, minimal FGF sevoflurane anesthesia during on-pump cardiac surgery is not associated with increased risk of postoperative AKI in this population at high risk for renal injury.


Acute kidney injury;  Sevoflurane;  Anesthesia;  Occupational health


1 S Ryan, J Sherman Sustainable anesthesia Anesth Analg, 114 (2012), pp. 921-923

2 H Higuchi, Y Adachi, S Arimura, et al. Compound A concentrations during low-flow sevoflurane anesthesia correlate directly with the concentration of monovalent bases in carbon dioxide absorbents Anesth Analg, 91 (2000), pp. 434-439

3 M Morio, K Fujii, N Satoh, et al. Reaction of sevoflurane and its degradation products with soda lime. Toxicity of the byproducts Anesthesiology, 77 (1992), pp. 1155-1164

4 LCL Ong Sio, RGC Dela Cruz, AF Bautista Sevoflurane and renal function: a meta-analysis of randomized trials Med Gas Res, 7 (2017), pp. 186-193

5 JM. Feldman Managing fresh gas flow to reduce environmental contamination Anesth Analg, 114 (2012), pp. 1093-1101

6 DY Fuhrman, JA. Kellum Epidemiology and pathophysiology of cardiac surgery-associated acute kidney injury Curr Opin Anaesthesiol, 30 (2017), pp. 60-65

7 Q Yi, K Li, Z Jian, et al. Risk Factors for Acute Kidney Injury after Cardiovascular Surgery: Evidence from 2,157 Cases and 49,777 Controls - A Meta-Analysis Cardiorenal Med, 6 (2016), pp. 237-250

8 AB. Baker Low flow and closed circuits Anaesth Intensive Care, 22 (1994), pp. 341-342

9 Cavalcanti IL, Vane LA. Inhalation Anesthesia. Rio de Janeiro: Brazilian Society of Anesthesiology; 2007. 156 p.

10 S Morita, W Latta, K Hambro, et al. Accumulation of methane, acetone, and nitrogen in the inspired gas during closed-circuit anesthesia Anesth Analg, 64 (1985), pp. 343-347

11 A. Khwaja KDIGO clinical practice guidelines for acute kidney injury Nephron Clin Pract, 120 (2012), pp. c179-c184

12 AS Levey, LA Stevens, CH Schmid, et al. A new equation to estimate glomerular filtration rate Ann Intern Med, 150 (2009), pp. 604-612

13 Eger EI 2nd, Koblin DD, T Bowland, et al. Nephrotoxicity of sevoflurane versus desflurane anesthesia in volunteers Anesth Analg, 84 (1997), pp. 160-168

14 C Goeters, C Reinhardt, E Gronau, et al. Minimal flow sevoflurane and isoflurane anaesthesia and impact on renal function Eur J Anaesthesiol, 18 (2001), pp. 43-50

15 ZX Fang, L Kandel, MJ Laster, et al. Factors affecting production of compound A from the interaction of sevoflurane with Baralyme and soda lime Anesth Analg, 82 (1996), pp. 775-781

16 ZX Fang, EI Eger 2nd Factors affecting the concentration of compound A resulting from the degradation of sevoflurane by soda lime and Baralyme in a standard anesthetic circuit Anesth Analg, 81 (1995), pp. 564-568

17 JM Murray, CW Renfrew, A Bedi, et al. Amsorb: a new carbon dioxide absorbent for use in anesthetic breathing systems Anesthesiology, 91 (1999), pp. 1342-1348

18 RH Epstein, F Dexter, DP Maguire, et al. Economic and Environmental Considerations During Low Fresh Gas Flow Volatile Agent Administration After Change to a Nonreactive Carbon Dioxide Absorbent Anesth Analg, 122 (2016), pp. 996-1006

19 H Higuchi, Y Adachi, S Arimura, et al. The carbon dioxide absorption capacity of Amsorb is half that of soda lime Anesth Analg, 93 (2001), pp. 221-225

20 KM Souza, LG Braz, FR Nogueira, et al. Occupational exposure to anesthetics leads to genomic instability, cytotoxicity and proliferative changes Mutat Res (2016), pp. 791-792 42-8

21 AA El-Ebiary, AA Abuelfadl, NI Sarhan, et al. Assessment of genotoxicity risk in operation room personnel by the alkaline comet assay Hum Exp Toxicol, 32 (2013), pp. 563-570

22 S Izdes, S Sardas, E Kadioglu, et al. DNA damage, glutathione, and total antioxidant capacity in anesthesia nurses Arch Environ Occup Health, 65 (2010), pp. 211-217

23 AG Aun, MA Golim, FR Nogueira, et al. Monitoring early cell damage in physicians who are occupationally exposed to inhalational anesthetics Mutat Res, 812 (2018), pp. 5-9

24 AM Gaffney, RN. Sladen Acute kidney injury in cardiac surgery Curr Opin Anaesthesiol, 28 (2015), pp. 50-59

25 PF Conzen, ED Kharasch, SF Czerner, et al. Low-flow sevoflurane compared with low-flow isoflurane anesthesia in patients with stable renal insufficiency Anesthesiology, 97 (2002), pp. 578-584

26 JA. Baum Low-flow anaesthesia Eur J Anaesthesiol, 13 (1996), pp. 432-435

27 Y. Ishizawa Special article: general anesthetic gases and the global environment Anesth Analg, 112 (2011), pp. 213-217

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