1

Alexandria Journal of Anaesthesia and Intensive Care

COMPARISON BETWEEN THE INDUCTION OF ANESTHESIA

USING SEVOFLURANE-NITROUS OXIDE , PROPOFOL OR
COMBINATION OF PROPOFOL AND SEVOFLURANE-NITROUS
OXIDE USING LARYNGEAL MASK AIRWAY(LMA) IN
HYPERTENSIVE PATIENTS
Mohamed Saad El-Din Tolba ,Montaser S A El-kassem, Hussien M Agameya*
Department of Anaesthesia and Intensive Care,
Faculty of medicine, Menofyia University,
Alexandria University*

ABSTRACT
In a double-blinded trial, 90 patients with stable hypertension were enrolled in this study.
Each group consisted of 30 patients. The induction in group S was by sevoflurane 4% + 50%
oxygen +50% nitrous oxide by inhalation using the tidal volume technique. The induction in
group P was by propofol 2mg/kg IV, and in group PS (combination group) was by propofol
1mg/kg followed by inhalation of 4% sevoflurane.The present study compared hemodynamic
changes, laryngeal mask airway (LMA) insertion time and any complications occurred in the
induction period between the three groups. LMA insertion time was significantly longer in the
sevoflurane group than in the other two groups. Mean arterial blood pressure (MAP) was
significantly lower within each group after induction in comparison to before induction. In all
the groups, LMA was successfully inserted in all patients. According to patients induction
was pleasant in 90% of patients in the propofol group and was 88% in the combination group
and 40% in the sevoflurane group. This study concluded that in the combination group there
is the advantage of patient satisfaction and rapid induction with no apnea which occurred
with propofol and had the advantage of hemodynamic stability encountered with sevoflurane.

INTRODUCTION
The induction of anesthesia in
hypertensive patients carries an increased
risk of adverse cardiovascular events in
hypertensive patients. Laryngoscopy is
often followed by increased arterial
pressure which may lead to myocardial
ischemia, transient ventricular failure and
arrhythmia[1-2]. LMA has been safely and
effectively used in spontaneous and
controlled ventilation. LMA can be inserted
successfully after suppression of airway
reflexes by deep anesthesia. Propofol is
an appropriate intravenous anesthetic
agent for rapid induction and suppression
of airway reflexes. Sevoflurane is an
alternative to propofol because it has a
pleasant odor, does not irritate the airways
and provides a rapid induction and
recovery.
Deeper
anesthesia
or
premedication with various agents, such
as beta blockade, opioids or calcium
inhibitors may limit this hypertensive
reaction but may be followed by

AJAIC-Vol. (9) No. 1 Marsh 2006

hypotension which is equally deleterious

in cardiac high risk patients [3-10] induction
by low dose propofol followed by
sevoflurane may be valuable in such
patients. Indeed low dose propofol
followed by sevoflurane has been shown
to be effective and well tolerated.[11-12] The
aim of this study was to compare, in
hypertensive patients, the hemodynamic
response to induction of anesthesia and
the incidence of complications between
these three methods of induction.
(sevoflurane-nitrous,
propofol,
and
propofol-sevoflurane methods)
PATIENTS AND METHODS
After consent of all patients, 90 ASA
classII patients, scheduled for elective
lower abdominal surgery were included in
this randomized study. Patients with
uncontrolled cardiovascular, pulmonary,
renal, liver dysfunction or smokers were
excluded from the study. Patients taking
angiotensin converting enzyme inhibitors
stopped taking the drug 24 hours before

Alexandria Journal of Anaesthesia and Intensive Care

the operation. The patients included in the
present study had a history of
hypertension for which they were being
treated and the admission blood pressure
was <160 mmHg systolic and <100 mmHg
diastolic. Patients were well-controlled
hypertension they normally continued their
medication up to, and including, the day of
surgery. Patients were allocated randomly
to three induction groups each one
consisted of 30 patients. Group S received
4%sevoflurane-N2O, group P received
propofol 2 mg/kg IV and group PS
received propofol 1mg/kg followed by
inhalation of 4% sevoflurane.

4.

5.

6.
Standardized monitoring using noninvasive blood pressure, heart rate,
electrocardiogram
(ECG),
oxygen
saturation (Spo2) and end-tidal partial
pressure of carbon dioxide (ETCO2) were
done for every patient. Hemodynamic
parameters
were
recorded
before
anesthesia was given (time 0). All patients
were given 1g/kg fentanyl IV and
breathed 100% oxygen via a facemask for
3 minutes before induction. After this,
group S received 4% sevoflurane (tidal
volume technique)[13-14] + 50% nitrous
oxide + 50% oxygen in 8L /min. Group P
received prpofol IV 2mg/kg at a rate of
40mg/10sec. Group PS received 1mg/kg
propofol at a rate of 40mg/10sec. followed
by 4% sevoflurane +50% nitrous oxide
+50%oxygen in 8L/min.
Parameters studied times:
1. heart rate and blood pressure of the
patients were measured before
induction (time 0) and 3 minutes after
induction of anaesthesia (time 1) and
immediately after LMA insertion (time
2) and 5 min after LMA insertion (time
3).
2. Loss of consciousness was detected by
loss of command communication and
confirmed by loss of eyelash reflexes.
The LMA was inserted after the
eyelash reflex had been lost.
3. Success with LMA insertion was
assessed by chest wall auscultation
and capnography. In all patients
anesthesia was maintained with
sevoflurane adjusted initially at 1.5%
end tidal concentration and adjusted
during the operation according to the

AJAIC-Vol. (9) No. 1 Marsh 2006

8.

9.

hemodynamic changes Rocurionium

0.6mg/kg was given to all patients and
controlled ventilation done for all
patients. Induction time was defined as
the interval from the beginning of
induction to loss of lid lash reflex.
Patient satisfaction was defined as
unfavorable if patients after recovery
stated that the induction was
unpleasant and favorable if patients
stated that the induction was pleasant.
various
The percentage of patients in whom the
LMA was inserted from the first
attempt was recorded.
The degree of jaw opening (good or
not) was assessed. 7.Occurence of
laryngospasm, cough, hiccupping
were assessed.
Apnea occurrence (cessation of
respiration for 20 sec.) was also
assessed.
the doses of Ephedrine sulphate
requirements.

Statistical analysis
The data are expressed as mean (SD),
percentage and numbers. Demographic
data were analysed with one-way anova
(ANOVA) and Chi Square. ANOVA and
repeated measures ANOVA were used for
the comparison of the hemodynamic
changes between and within the three
groups respectively. P <0.05 was
considered to be significant.

RESULTS
All patients were comparable with
respect to age, sex, weight (Table 1).
Before the induction of anesthesia (time
0), there was no significant difference in
MAP between the three groups (figure1).
After induction (time 1), there was
significant decline in MAP(Mean Arterial
Blood Pressure) in each group compared
to the MAP before induction and the
propofol group showed significant decline
in MAP compared to sevoflurane group
and the combination group and there was
no significant difference detected between
the
sevoflurane
group
and
the
combination group. After LMA insertion
(time 2) and 5 minutes after the LMA
insertion (time 3) there was significant

Alexandria Journal of Anaesthesia and Intensive Care

decline in MAP in the propofol group
compared to the other two groups but no
significant difference detected between
the sevoflurane and the combination
group. Within the propofol group at these
times there was significant decline in MAP
compared to preinduction level. At these
two times, no significant difference was
detected withen the sevoflurane group or
the combination group compared to
preinduction level.
Before induction, there was no
significant difference in HR between the
three groups. After induction, there was a
significant decline in HR in the sevoflurane
group compared to preinduction level
(figure 2). In the propofol group and in the
combination group, there was no
significant difference in HR compared to
preinduction, also at this time there was
significant decline in HR in the sevoflurane
group compared to the other two groups
but no significant difference was detected
between the propofol group and the
combination group. After LMA insertion
and 5 minutes after the insertion there
was significant increase in HR in the
propofol group compared to the other two
groups but no significant difference in HR
was detected between the sevoflurane
group and the combination group. Also at
these two times, there was significant
increase in HR in the propofol group
compared to preinduction level and there
was significant decrease in HR in the
sevoflurane
group
compared
to
preinduction level, but no significant
change was detected at these two times in
the combination group compared to the
preinduction levels. (Table 2)

Induction time
Induction time was significantly
longer in the sevoflurane group compared
to the propofol group and the combination
group (figure 3).
But no significant difference was
detected between the propofol group and
the combination group (table 3) .

AJAIC-Vol. (9) No. 1 Marsh 2006

LMA Insertion from the first attempt

LMA was inserted from the first
attempt in 80% of patients in the
sevoflurane group and it was inserted
from the first attempt in all patients of the
other two groups (table 3).

Satisfaction
Only 40% of patients in the
sevoflurane group were pleasant with the
induction but 90% of patients were
pleasant in the propofol group and 88% of
patients were pleasant in the combination
group (table 3).

Jaw opening
20% of patients in the sevoflurane
group had difficulty in jaw opening .no
patient in the other two groups had such
difficulty (table 3).

Apnea
40% of patients in the propofol group
had apnea but no patient had apnea in the
other two groups (table 3).
Laryngeal spasm
No patient in the present study had
laryngospasm (table 3).
Cough
Only one patient had cough during
the induction in the sevoflurane group no
patient had cough in the other two groups
(table 3).
Hiccups
Only one patient had hiccough
during the induction in the sevoflurane
group, no patient had hiccough in the
other two groups (table 3).
Ephedrine requirements
There was significant increase in
ephedrine requirements in the propofol
group compared to the other two groups
(P<0.05), but no significant difference was
detected between the sevoflurane group
and the combination group.

Alexandria Journal of Anaesthesia and Intensive Care

Table (1): Demographic criteria of the studied groups.

Group S (n=30)
Group P (n=30)
Group PS (n=30)
Age (Y)
60.2(4.4)
60.3(4.3)
59.8(4.9)
Gender M/F
15/15
16/14
14/16
Weight (Kg)
72.9(2.2)
71.8(2.9)
70.9(2.7)
Data are expressed as Mean(SD).
Table (2): Changes in heart rate and Mean Arterial Blood Pressure in the studied
groups at various times.

Group S
Group P
Group
PS
Group S
Group P
Group
PS

Time 0
110.3
(10.4)
108.1
(9.6)
109.3
(10.2)
80.3
(8.4)
80.2
(8.6)
80.6
(7.9)

Time 1
90.6
(8.3)*
80.8
(10.2)*
92.6
(9.3)*
65.6
(7.4)*
78.9
(8.4)
80.1
(6.7)

Time 2
115.8
(7.2)
90.4
(9.3)*
114.2
(6.8)
66.4
(9.2)*
90.6
(7.3)*
80.2
(9.9)

Time 3
112.5
(7.4)
80.6
(10.3)*
110.3
(7.8)
68.8
(7.2)*
92.2
(8.1)*
82.3
(7.8)

P
0.001
0.0001
0.001
0.001
0.001
0.12

Data are expressed as Mean(SD).

*P<0.05 within the group in relation to preinduction (time0).

Table (3): incidence of complications in the studied groups :

Induction time (sec.)

LMA insertion from the 1st attempt
Patient satisfaction (percent)
Jaw opening difficulty (no.)
Apnea (percent)
Laryngospasm (no)
Cough (no)
Hiccupping (no)
Ephedrine requirements (mg)

Group S

Group P

Group PS

150.6
(15.2)
80%
40%
6

65.9
(14.7)*
100%
90%
0

70.1
(13.9)*
100%
88%
0

0
0
1
1
2.1(1.1)

40%
0
0
0
9.3(4.2)*

0
0
0
0
2.2(0.8)

Data are expressed as Mean(SD). And as percentages in in LMA insertion and Apnea.
*P<0.05 is significant *P<0.01 in comparison to group S

AJAIC-Vol. (9) No. 1 Marsh 2006

Alexandria Journal of Anaesthesia and Intensive Care

Fig.1: Changes in MAP

120
100
80
MAP

Group S
Group P
Group PS

60
40
20
0
Time 0 Time 1 Time 2 Time 3
Time

Fig.2: Changes in heart rate

100
90
80
70
60
HR 50
40
30
20
10
0

Group S
Group P
Group PS

Time 0 Time 1 Time 2 Time 3

Time

AJAIC-Vol. (9) No. 1 Marsh 2006

Alexandria Journal of Anaesthesia and Intensive Care

Fig 3: induction time among the three groups

160
140
120
100
Time(secs.) 80
60
40
20
0

Induction time (sec.)

Group S Group P Group

PS
Groups

Discussion
Sevoflurane
is
an
alternative
anesthetic induction agent to propofol
since it has a pleasant odor, does not
irritate the airways, provide a rapid
induction [8-9], however sevoflurane has a
longer induction time than propofol [8]. In
the present study, induction time with 4%
sevoflurane was 150 (15) sec., and was
65 (15) sec. with propofol and was 70(12)
sec. in the combination group. Thwaites et
al, [15] reported that induction with propofol
was pleasant in 70% of patients and was
45% in patients induced by sevoflurane. In
the study done by Bapat et al, [16] 90% of
patients induced by propofol preferred the
method while only 25%of the patients
induced by sevoflurane preferred the
method. In the present study 90% of
patients induced by propofol were
satisfied, and 88% of patients induced by
the combination of propofol and
sevoflurane were satisfied, but only 30%
of patients induced by sevoflurane were
satisfied.
As regard hemodynamic changes Ti
et al, [17] detected significant decrease in
MAP and insignificant rise in heart rate
(HR) after induction with propofol
compared to induction with sevoflurane,
while Fredman et al,[18] in his study

AJAIC-Vol. (9) No. 1 Marsh 2006

comparing the induction by sevoflurane

versus propofol detected a decrease in
MAP and HR after induction in
comparison to preinduction values, his
study also detected that the decrease in
HR in the sevoflurane group was more
significant than that in the propofol group.
Jellish et al,[19] detected significant
decrease in MAP after propofol induction
compared to sevoflurane induction in adult
patients. The present study suggested
that there was significant decrease in
MAP in the patients induced by propofol
compared to those induced by sevoflurane
or those induced by the combination of
propofol and sevoflurane, but there was
significant decrease in HR in the
sevoflurane group compared to the
propofol and the combination group.
As regard the degree of jaw
opening, Muzi et al, [20] encountered
difficulty in jaw opening in 30% of patients
induced by sevoflurane. TI ei al, [17]
encountered difficulty in jaw opening in
45% with sevoflurane and in 21% of
patients induced by propofol. In our study
difficulty in jaw opining occurred in 20% of
patients in the sevoflurane group. Jaw
opening was adequate in all patients in
the other two groups. LMA was inserted
from the first attempt in all patients in the
propofol group and in the combination

Alexandria Journal of Anaesthesia and Intensive Care

group but was inserted in 80% of patients
induced by sevoflurane from the first
attempt, however LMA was successfully
inserted in all patients.
In the study done by TI et al,[17], LMA
was inserted after 1.2 (0.6) attempts with
propofol and in 1.6 (0.7) attempts with
sevoflurane and detected significant
difference between the two groups.
In the study done by Fleischmann et al,[21],
LMA was inserted from the first attempt
with propofol in 85% of patients and in
75% with sevoflurane this differences in
the results may be explained by the
different doses and concentrations of
propofol and sevoflurane used by the
investigators.
The present study showed that
laryngospasm was not encountered in any
patient of the three groups but in the study
done by Molloy et al,[22], Laryngospasm
was encountered in 10% of patients
received propofol and in 20% of patients
received sevoflurane this difference in the
results may be explained by the higher
rate of injection of propofol and the higher
sevoflurane concentration (6%) used by
Molloy et al, [22].
In the present study cough was
encountered in only one patient during
induction in the sevoflurane group and no
patient had cough during induction in the
other two groups. In the study done by
Molloy et al,[22]. Cough was encountered in
13% of patients received propofol and in
25% of patients received sevoflurane. This
difference in the results may be explained
by the higer rate of injection of propofol
and the higher sevoflurane concentration
(6%) used by Molloy et al,[22] .
As regard hiccups, in this study, only
one patient had hiccups in the sevoflurane
group and hiccup was not detected in any
patient of the other two groups. In the
study done by Philip et al,[23], 6% of
patients who received sevoflurane had
hiccup and 2% of patients who received
propofol had hiccups.
CONCLUSION
with

In our study it seems that induction

propofol 1mg/kg followed by

AJAIC-Vol. (9) No. 1 Marsh 2006

inhalation of 4% sevoflurane is better than

the induction with either sevoflurane or
propofol alone because in the combination
group there is the advantage of patient
satisfaction and rapid induction with no
apnea which occurred with propofol and
had the advantage of hemodynamic
stability encountered with sevoflurane.

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