• Stanley Leeson, Russell S Roberson, and James H Philip.
• From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
• Anesth. Analg.. 2014 Oct 1;119(4):829-35.

BackgroundDuring emergence from volatile anesthesia, hypoventilation may result from many causes. In this study, we examined the effect of hypoventilation after initial emergence from volatile anesthesia and the potential for reanesthetization.MethodsThe uptake and excretion of desflurane (Des), sevoflurane, and isoflurane were studied using the Gas Man® computer simulation program for a 70-kg simulated patient. The vaporizer setting was adjusted so that a VRG (vessel-rich tissue group, including brain) level of 0.75 minimum alveolar concentration (MAC), 1.0 MAC, and 1.5 MAC was rapidly achieved and maintained within tight limits for a 1-, 2-, 4-, and 6-hour period of anesthesia.At the end of the simulated period of anesthesia, the vaporizer was set to 0 and fresh gas flow was set to 8 L/min. Ventilation (VA) was continued at 4 L/min until the anesthetic level in the VRG reached MAC awake, equal to 0.33 MAC for each drug. Then, the VA was adjusted to 0.1 L/min to simulate near-apnea and 0.0 L/min to simulate true apnea. Severe reanesthetization was said to occur if the VRG level increased to or above 0.5 MAC. Mild reanesthetization was said to occur if VRG increased from its value of 0.33 MAC but did not reach 0.5 MAC. The minimum VA required to avoid severe reanesthetization was studied by trials of decreased VA beginning at the time the VRG reached 0.33 MAC.ResultsAfter emergence from 1 hour of anesthesia, all simulated patients were protected against mild and severe reanesthetization if anesthesia was at 0.75 or 1.0 MAC. After 4 or 6 hours of anesthesia, severe reanesthetization occurred with all drugs with near or true apnea if anesthesia was at 1.0 or 1.5 MAC. The minimum alveolar VA to protect against severe reanesthetization after 6 hours of anesthesia was no more than 0.5 L/min for all drugs at 0.75 MAC, no more than 0.5 L/min at 1.0 MAC, and no more than 1.2 L/min at 1.5 MAC. In all simulated cases, the source of anesthetic drug that allowed reanesthetization was muscle (MUS), which reached a value of 0.8 MAC within 4 hours with all drugs and reached a value of 0.75 MAC with desflurane after 2 hours. Fat levels of anesthetic remained less than 0.15 MAC for all drugs up to the 6 hours tested.ConclusionsReanesthetization from hypoventilation after inhaled anesthesia is possible. After initial emergence, muscle is a source of anesthetic and predisposes to reanesthetization while fat is a sink for anesthetic and fosters continued emergence. Severe hypoventilation will cause some degree of reanesthetization from anesthetic released from muscle after 4 hours of 1 MAC inhaled anesthesia with desflurane, sevoflurane, or isoflurane.

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