Low Flow and High Flow Anesthesia on Thiol-Disulfide Homeostasis and IMA in Laparoscopic Cholecystectomy Surgery
Condition: Laparoscopic Cholecystectomy
Study type: Interventional

Summary: 
      Comparison of the Effects of Low Flow and High Flow Anesthesia on Thiol-Disulfide Homeostasis
      and Ischemia Modified Albumin in Laparoscopic Cholecystectomy Surgery

      In this study, our aim is to compare the effects of Low Flow and High Flow Anesthesia on
      Thiol-Disulfide Homeostasis and Ischemia Modified Albumin in laparoscopic Cholecystectomy
      Surgery using Sevoflurane as an anesthetic gas routinely.
    

Detailed description: 
      General anesthesia is characterized by reversible loss of consciousness, analgesia in the
      whole body, amnesia, and some muscle relaxation. Induction, which is the initial phase of
      anesthesia, can be performed with intravenous or inhalation anesthetics. The most common
      practice today for maintenance of anesthesia after induction is to add an effective low
      intensity inhalation anesthetic to the oxygen, nitrous oxide or oxygen,air mixture. Although
      new inhalation agents provide some advantages over old ones, they are more costly. This
      situation has brought the development of new anesthetic techniques to the agenda. Interest in
      low fresh gas flow anesthesia methods has been increasing in recent years. The high standard
      of anesthesia machines, the availability of monitors that continuously analyze the anesthetic
      gas composition, and the increase in knowledge on the pharmacokinetics and pharmacodynamics
      of inhalation anesthetics have greatly facilitated the safe application of low-flow
      anesthesia. The term low flow anesthesia is used to describe inhalation anesthesia techniques
      with a semi closed rebreathing system with a reventilation rate of at least 50%, and with the
      help of a reversible anesthesia system, after the carbon dioxide is removed from the expired
      gas mixture from the patient, the metabolic requirements of the body are determined. At least
      50% of the fresh oxygen flow is given back to the patient together with the volatile
      anesthetics in sufficient quantity. Many different anesthesia applications with different
      fresh gas flow rates have been described. Very high flow > 4 L / min, High flow 2-4 L / min,
      Medium flow 1-2 L / min, Low flow 500-1000 mL / min, Minimal flow 250-500 mL / min, Metabolic
      flow <250 mL / min. Currents of 1 L / min and below enter the low flow anesthesia head. The
      low flow anesthesia we use routinely has many advantages for the patient. Increasing the
      respiration rate of the humidified and warmed exhaled gas is of great importance for the
      function of the ciliated epithelium and for mucociliary cleaning, it provides a significant
      reduction in postoperative sore throat. It has an economic advantage due to the reduction in
      anesthetic gas consumption. It reduces exposure to anesthetic gases in the operating room
      environmen ; hypoxia, incompatibility of anesthesia depth, hypercarbia, possibility of heat
      accumulation and increased risk of bacterial contamination. Safety Features in Anesthesia
      Machines; According to the European common standard EN 740 conditions; They have features for
      monitoring inspired oxygen concentration, Monitoring of inhaled CO2 concentration, Monitoring
      of Volatile anesthetic concentration, Oxygen support insufficiency alarm, Oxygen bypass,
      Oxygen rate monitor. Although the risk is very low in low flow, oxygen in inspired fresh gas
      to avoid hypoxia Its concentration should be at least 50%. Depth of anesthesia can be
      adjusted according to the sevoflurane gas concentration in the monitor. Inspired and expired
      CO2 monitoring is important for patient safety. In order to prevent hypercarbia, appropriate
      carbon dioxide absorbent should be used and frequent replacement should be provided.
      Bacterial filters should also be used in the breathing circuit to prevent heat build-up and
      bacterial contamination. In high-flow anesthesia, drying of the respiratory tract and a
      decrease in mucociliary activity occurs. The use of a breathing circuit with a moisture
      retaining chamber and a moisture retaining filter can prevent this situation. Increasing
      anesthetic gas consumption increases the cost of the anesthetic gas in the surgical
      environment.

      The use of volatile anesthetics such as desflurane or sevoflurane during general anesthesia
      causes an increase in lipid peroxidation or proinflammatory cytokines in macrophages, leading
      to generalized inflammatory reactions. It is stated that all these can cause oxidative
      stress, and under general anesthesia, patients are exposed to oxidative stress caused by
      volatile anesthetics. However, laparoscopic cholecystectomy, which has become a common
      procedure due to its advantages, increases the intraabdominal pressure, liver, splanchnic
      vessels, mesenteric hypoxia, ischemia. It causes reperfusion damage and consequently an
      increase in oxidative stress. Sevoflurane is a widely used anesthetic agent, its
      anti-inflammatory and antioxidant properties have been demonstrated in various studies, it
      has been shown that it protects against ischemia-reperfusion damage in vital organs such as
      heart, lung and kidney, and has more protective effects on thiol disulfide homeostasis than
      desflurane.

      Thiols are compounds containing sulfur group, which are essential antioxidant buffers that
      interact with almost all physiological oxidants. Thiol groups are oxidized by the surrounding
      oxidant molecules and converted to disulfide structures and then thiol groups, thiol
      disulfide balance was a sustainable reaction. Thiols act as fast electron acceptors and play
      an important role in defending against reactive oxygen species by contributing a large part
      of the total antioxidants present in the body. Plasma thiols have pro-oxidant or antioxidant
      effects on physiological events; but they are generally regarded as antioxidants. It also
      plays a critical role in programmed cell death, detoxification, antioxidant protection and
      regulation of cellular enzymatic activity. Measuring thiols in serum may show an indirect
      reflection of antioxidant defense. Another oxidation parameter that can be used as a
      perioperative ischemia marker is ischemia-modified albumin (IMA). Hypoxia, acidosis, and
      superoxide radical damage cause IMA formation by altering the structure of the N terminal,
      reducing the binding capacity of albumin to metals. IMA is an early-rising indicator of
      ischemia, it increases in as little as 6 minutes. Anesthesia method, surgical method,
      medications used, infection and operation time affect postoperative morbidity and mortality
      by changing the stress response.
    

Intervention name(s): low and high flow Anesthesia
Intervention type(s): Procedure
Intervention description(s): comparison of hemodynamic changes in low and high flow anesthesia groups
Other intervention name(s): Cholecystectomy Surgery
Intervention MeSH terms: Anesthetics
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Screening
Keywords: Low Flow; High Flow; tiyol-disülfid homeostasis; Modified Albumin