Changing aspects of sevoflurane in paediatric anaesthesia: 1975–99

first volunteer trials were reported in 1981 (2). sevoflurane for the first time of course wants to Although the results were encouraging, sevoflurane compare it with halothane, the well known and was not released on the market for many years which extremely safe agent in prepuberty. However, the led to the surprised question in an editorial in 1992: reader might be confused when studying more than If this inhalation anaesthetic is so good, where has 200 articles from the vast body of sevoflurane it been all these years? (3). The authors surmised that literature, finding the data demonstrating a shorter isoflurane, marketed with its cardinal virtue of low induction time unconvincing, wondering about biotransformation and constituting the most potent occasional seizures during induction and the high argument for acceptance of an inhalation anaesthetic requirements for the anaesthetic during maintenance, of that decade, prohibited the release of an agent and being alarmed by contradicting information with a higher biotransformation and a breakdown in about emergence times, incidence of postoperative sodalime to possibly toxic products. agitation, delirium and early pain (4–12,14–25). However, in 1992 sevoflurane was licensed in The first striking impression gained from reading Japan, in 1995 by the Food and Drug Administration the literature is the obvious neglect of comparable (FDA) in the USA, despite a rather high bioMAC-values (minimal anaesthetic concentration at transformation, conflicting data on the quality of which 50% of patients move on skin incision) in induction (4,5), seizures during induction and different studies. The average induction dose of an maintainance (6–8), and moderate elevations inhalation anaesthetic comprises 2–3 MAC. These of plasma inorganic fluoride and compound A values are well established for both anaesthetics in concentrations (9–11), as well as a high incidence of question. One MAC sevoflurane in children (> 1 year) emergence excitement or even delirium compared to is approximately 2.5 vol%, with 60% nitrous oxide at halothane (12). approximately 2.0%, which is only 25% lower (9, Since the release of sevoflurane by the FDA in 26), whereas one MAC halothane is approximately 1995, it was used with increasing popularity in many 0.9 vol% in this age group, which decreases with institutions. Only 2 years later, the question was 60% nitrous oxide down to approximately 0.35 vol%, discussed in an editorial: Is there still a place for which is 60% lower (27,28). halothane in paediatric anaesthesia? (13). The author This means that a comparison between 5 vol% found a few remaining indications for halothane. halothane and 8 vol% sevoflurane without nitrous What has caused the rapid change of mind in many oxide (14) actually compares 5.4 MAC halothane with anaesthetists? Was the rate of biotransformation of 3.2 MAC sevoflurane. On the other hand, 3% anaesthetics not that important after all? Are seizures halothane is almost equivalent to 7.0% sevoflurane and delirium not alarming side-effects? Is the but, adding nitrous oxide, approximately 7.5 MAC community of anaesthetists subject to fashion and halothane are compared with 3.5 MAC sevoflurane inclined to believe in elegantly staged marketing (15). The frequently quoted study with a highly strategies of industry rather than clinical observasignificant incidence of dysrhythmias in the tions? Or is sevoflurane simply a better anaesthetic halothane group compares 11 MAC halothane with than all other inhalational agents? 4 MAC sevoflurane (16). Holzman et al. (17) report