ABSTRACT
Normothermic machine perfusion (NMP) of donor kidneys provides an opportunity not only for organ preservation but also for therapeutic intervention to reduce ischemia–reperfusion injury (IRI) and support tissue repair. Sevoflurane, a volatile anesthetic known to protect against IRI in other organ systems, has not previously been explored in the context of kidney NMP. This study aimed to establish a stable and reproducible porcine kidney NMP model incorporating sevoflurane delivery. Different administration techniques and oxygenator setups were evaluated to identify the most effective method of sevoflurane application. Administering sevoflurane directly as a liquid into the perfusate resulted in excessive gas formation and unstable drug concentrations. In contrast, using a vaporizer connected to an Inspire 8F M oxygenator allowed for stable and reproducible sevoflurane levels over a 90‐min perfusion period, while maintaining sufficient oxygenation. This method proved to be a reliable approach for sevoflurane delivery in kidney NMP. However, oxygenators exposed to sevoflurane should not be reused due to the risk of membrane damage. These findings support the feasibility of using sevoflurane in kidney NMP and provide a platform for further investigation into its potential to improve renal graft outcomes.
A stable kidney normothermic machine perfusion model with sevoflurane delivery via a vaporizer was established, enabling mechanistic and therapeutic studies of ischemia–reperfusion injury.
1. Introduction
Kidney transplantation is the only curative treatment for patients with end‐stage renal disease (ESRD), offering superior survival and quality of life compared with dialysis. However, the number of donor organs remains far below the growing clinical demand, making the optimization of marginal kidneys and expansion of the donor pool an urgent clinical priority [1].
A major challenge in transplantation is ischemia reperfusion injury (IRI), a leading cause of early graft dysfunction, impaired outcomes, and rejection [2, 3, 4, 5]. IRI is driven by mitochondrial injury, oxidative stress, endothelial dysfunction, and immune activation, ultimately culminating in inflammation [2, 3, 4, 5]. Strategies to mitigate IRI are therefore critical to improving graft performance and expanding the utilization of donor kidneys.
Among potential protective agents, sevoflurane, a volatile anesthetic, has shown beneficial effects against IRI in multiple organ systems [6, 7, 8, 9]. Evidence supports its cardioprotective role during myocardial IRI [6], while in renal models it has been shown to reduce creatinine levels and suppress inflammatory cascades [10]. Proposed mechanisms include inhibition of mitochondrial permeability transition, suppression of immune activation, endothelial protection, and upregulation of hypoxia inducible factor‐regulated genes [9, 11, 12, 13]. However, mechanistic studies remain limited, and its application in kidney transplantation has not yet been systematically investigated.
Due to the physicochemical properties of sevoflurane, being liquid at room temperature and typically administered via inhalation, clinical transplantation studies have focused mainly on sevoflurane as donor preconditioning or recipient postconditioning [13, 14, 15, 16]. To date, no studies have evaluated its direct application during ex vivo organ preservation.
Normothermic machine perfusion (NMP) provides an innovative preservation strategy, enabling real‐time functional assessment and targeted delivery of therapeutic agents, thereby offering a unique opportunity to mitigate IRI and improve graft viability [17, 18]. The aim of this study was to develop a stable porcine kidney NMP model incorporating sevoflurane administration. The primary outcome was to determine whether stable perfusate concentrations of sevoflurane could be achieved during NMP. By addressing delivery challenges, this model establishes a platform for future investigations into sevoflurane as a therapeutic strategy to mitigate IRI and enhance renal graft outcomes.
2. Materials and Methods
2.1. Kidney and Blood Preservation
Porcine kidneys and matched blood were obtained from Kroon Vlees slaughterhouse in Groningen, The Netherlands, ensuring no additional animals were sacrificed. Pigs were terminated via a standardized procedure, followed by exsanguination. Four liters of blood were obtained approximately 2 min after the death of the animal and added to 5 mL of Heparin (5.000 IE/mL) after which it was filtered through 2 layers of gauze pads and stored in 3–4 CPDA‐1 bags (CompoFlex, CPDA‐1, Fresenius Kabi AG Bad Homburg, Germany). Kidneys were procured 10–20 min after death, inspected for damage, and excess adipose tissue was removed. The renal arteries were cannulated. After 30 min of warm ischemia time (WIT), the kidneys were flushed with 500 mL of cold UW‐solution (Belzer UW Cold Storage Solution, Bridge to Life (Europe) Ltd., London). A catheter was inserted into the ureter, a sample line was sutured to the renal vein, and the kidneys were placed on ice for transportation and storage for 24 h (cold ischemia time, CIT). Blood was centrifuged for 20 min at 20°C and 2000 RCF, the upper plasma was removed, and the remaining blood cells were then washed with 1× Phosphate Buffered Saline (Na2HPO4•2H2O, KH2PO4, NaCl). This process was repeated twice.
2.2. The General NMP Setup
The general NMP circuit consisted of one or more oxygenator(s), an arterial limb, an organ chamber, a venous limb, and a centrifugal pump (Figure 1). Depending on the experiment, one to three oxygenators were used, and four different types of oxygenators were tested, as specified in each experiment. The gas mixture consisted of 95% O2/5% CO2. Multiple flow rates were evaluated. A Flurosorb canister (Sedana Medical, Danderyd, Sweden) was employed to provide anesthetic gas scavenging.
FIGURE 1.
The general NMP setup. [Color figure can be viewed at wileyonlinelibrary.com]
2.3. The Perfusion Fluid
The perfusate was prepared on the day of the experiment. Perfusate consisted of sterile water 140 mL (Versylene Fresenius Kabi AG, Bad Homburg, Germany), NaCl 0.9% 380 mL (Versylene Fresenius Kabi AG, Bad Homburg, Germany), albumin 20% 150 mL (Albuman 200 g/L, Prothya Biosolutions Netherlands), Cernevit 0.5 mL (diluted in 5 mL 0.9% NaCl, Baxter B.V. Utrecht), cefazoline 1 g (diluted in 10 mL sterile water, Mylan BV, Amstelveen), sodium bicarbonate 8.4% 27 mL (B. Braun Melsungen AG, Germany), magnesium sulphate 1 mL (100 mg/mL, Kalcex, Latvia), sodium phosphate 0.25 mL (15 mmol phosphate = 5 mL, Apotheek, Netherlands), aminoplasmal 10% 3.5 mL (B. Braun Melsungen AG, Germany), calcium gluconate 10% 8 mL (B. Braun Melsungen AG, Germany), creatinine 0.06 g (Sigma‐Aldrich, America) and glucose 5% 19 mL (Baxter B.V. Utrecht). The NMP circuit was primed with this perfusate, after which 370 mL of washed red blood cells was added.
2.4. Sevoflurane Administration
Two routes of sevoflurane administration were tested: (1) continuous injection of liquid sevoflurane directly into the arterial limb of the perfusion system using a syringe pump (BD Alaris GH Plus Syringe Pump, New Jersey, USA), and (2) administration of sevoflurane in gaseous form via a vaporizer (Sevorane, ABBOTT, Dräger, Lübeck, Germany) connected to the gas inlet of the oxygenator.
To prevent environmental pollution, all experiments were conducted under a fume hood, and the NMP circuit was sealed gas tight. Openings in the kidney‐containing box for arterial and venous connections, urinary and venous sample lines, and pressure measurements were sealed with Parafilm M.
“Inspired” sevoflurane concentration was regulated by the dosage given via the vaporizer or syringe pump. “Expired” sevoflurane concentration was measured at the outflow outlet of the oxygenator with the gas monitor (Vamos, Dräger Medical, Lübeck, Germany). When sevoflurane measurement at a second oxygenator was required, an additional gas monitor (Datex‐Ohmeda S/5, GE Healthcare, Chicago, IL, USA) was connected to its outflow outlet.
Calibration details: Vamos, per manufacturer guidance, the gas measurement module auto‐calibrates every 2 h (≈30 s “CAL” cycle) and can be manually initiated via the main menu; SpO2 requires no calibration. Datex‐Ohmeda S/5, per manufacturer guidance, the module performs a self‐calibration at start‐up (indicated by “Calibrating gas sensor”); calibrations were performed after ≥ 30 min warm‐up.
2.5. Oxygenators
Four different types of oxygenators were tested: (1) Medos Hilite 1000 infant (Medos AG, Stolberg, Germany), (2) Inspire 8F M (LivaNova, London, United Kingdom), (3) Maquet Quadrox I Small Adult (Maquet GmbH, Rastatt, Germany), and (4) Maquet Quadrox I Neonatal (Maquet GmbH, Rastatt, Germany).
| Oxygenator model | Membrane surface area | Membrane material | Flow range | O2 transfer, mL/min |
|---|---|---|---|---|
|
Medos Hilite 1000 infant |
0.39 m2 | polypropylene | 0.2–1.0 L/min | 80 |
|
LivaNova Inspire 8 F M |
1.75 m2 | PMP with PC coating | 8 L/min | 450 |
|
Maquet Quadrox I Small Adult |
1.3 m2 | Polypropylene | 0.5–5 L/min | 400 |
| Maquet Quadrox I Neonatal | 0.38 m2 | Polypropylene | 0.2–1.5 L/min | 100 |
Note: O2 transfer values are approximate and derived from manufacturer performance curves. PMP with PC coating means polymethylpentene with phosphorylcholine coating.
2.6. Measurements and Samples
Venous, arterial, and urinary samples were taken at standardized time points (T‐30, T‐15, T‐5, T0, T10, T30, T40, T60, T75, T90, T105, T120), where T‐30, T‐15, and T‐5 corresponded to the priming phase prior to perfusion, and T0–T120 corresponded to the perfusion phase. Perfusion parameters recorded at these intervals included perfusate flow, temperature, gas flow, concentration of “inspired” sevoflurane, “expired” CO2, and sevoflurane. Blood gas samples (arterial and venous) were collected at T0, T60, and T120 and analyzed immediately using an ABL 90 FLEX PLUS blood gas analyzer (Radiometer, Copenhagen, Denmark). Samples were centrifuged at 1800 RCF for 10 min at 4°C, and the supernatant was stored at −80°C. Sevoflurane levels in the perfusate were measured at the University Hospital Clermont‐Ferrand, France, using head‐space gas chromatography as described by Bourdeaux et al. [19].
2.7. Outcome Measures
The primary outcome was a stable and reproducible sevoflurane concentration in the perfusate for 90 min.
Secondary outcomes included sevoflurane concentration in the “expired” air, as well as pH and the partial pressures of oxygen (pO2) and carbon dioxide (pCO2).
2.8. Statistical Analysis
All data are presented as mean ± standard deviation, unless otherwise noted. Normality was assessed using the Shapiro–Wilk test. Normally distributed continuous variables were analyzed with paired t‐tests, while differences among means were evaluated using one‐way or two‐way ANOVA. For non‐normally distributed data, mixed effect models were employed. Correlation analysis utilized linear regression models, with correlation coefficients (r): 0–0.3 (negligible), 0.3–0.5 (weak), 0.5–0.7 (moderate), 0.7–0.9 (strong), and 0.9–1.0 (very strong). Analyses were conducted using GraphPad Prism version 9 (GraphPad Software, Boston, Massachusetts, USA).
3. Results
3.1. Pilot 1; Continuous Injection of Liquid Sevoflurane
As a first step, sevoflurane was administered in liquid form directly into the arterial line of the perfusion circuit. It was aspirated from a 250 mL bottle (AbbVie B.V. Hoofddorp, Netherlands) into a 50 mL syringe, which was connected to the arterial limb via a 50 cm luer‐lock lectroCath (Vygon, Paris, France) and placed in a syringe pump (see Figure 2). A Medos Hilite 1000 infant oxygenator was used for oxygenation, with a Vamos gas monitor attached to the outflow for measuring sevoflurane gas concentrations. A shunt connection from the oxygenator to the organ chamber was installed to remove excess gas. Various infusion speeds and boluses were tested, with boluses given if sufficient sevoflurane concentrations at the venous limb were not reached. During the first 9 h of this experiment, no kidney was connected. This time was needed to create a steady state of the measured sevoflurane concentration. Then, the kidney was connected. Throughout the entire experiment, there was considerable gas formation in the circuit. An installed shunt from the oxygenator to the organ chamber could only prevent this to a certain extent. The measured sevoflurane values in the “expired” air were highly unstable and not reproducible. Even when maintaining a fixed injection speed, the measured sevoflurane values changed considerably (Figures 3 and 4). They seemed not to reflect the administered sevoflurane levels. Manipulation of the gas, for example via knocking on the outside of the oxygenator, seemed to increase the measured sevoflurane in the “expired” air.
FIGURE 2.
Experimental set‐up pilot 1. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 3.
Pilot 1. Measured sevoflurane values (by Vamos) for given injection speeds.
FIGURE 4.
Pilot 1. Measured sevoflurane concentrations (by Vamos) in real time.
3.2. Pilot 2; Administration of Sevoflurane With a Vaporizer
In pilot 2, sevoflurane was administered in its gaseous form with the use of a vaporizer attached to one oxygenator (oxygenator 1, Figure 5).
FIGURE 5.
Experimental set‐up pilot 2. (This circuit was not connected to kidneys; the kidneys shown serve illustrative purposes only). [Color figure can be viewed at wileyonlinelibrary.com]
Pilot 2 was subdivided into three groups (A, B, C), each testing different types of oxygenators and gas flows, as detailed in Appendix A. Three oxygenators were installed in line in the perfusion circuit to better understand their abilities to delivery and eliminate sevoflurane from the system.
In group A, a Maquet Quadrox‐I Small Adult oxygenator was used as oxygenator 1, and two Maquet Quadrox‐I Neonatal oxygenators were used as oxygenators 2 and 3.
In group B, an Inspire 8F M oxygenator was used as oxygenator 1, and two Medos Hilite 1000 infant oxygenators were used as oxygenators 2 and 3.
In both groups A and B, the same gas flows were given over all 3 oxygenators. Oxygenator 2 was attached to a Datex gas monitor and oxygenator 3 to a Vamos gas monitor. Gas flows of 0.2, 0.3, 0.4, 0.5, and 0.6 L/min were tested. This was done in both groups with an administered sevoflurane concentration of 2% and 4%. After both gas monitors suggested a steady state of sevoflurane was reached, perfusate samples were taken. At every sample point, 2 perfusate samples were taken, one from the venous limb and one between oxygenators 2 and 3 (middle samples). At all time points, the concentrations in those middle samples were lower than in the venous samples but never reached zero (Figures 6 and 7).
FIGURE 6.
Pilot 2. Group A. Sevoflurane concentration in the perfusate for different gas flows. Middle refers to the sample sight between oxygenators 2 and 3. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 7.
Pilot 2. Group B. Sevoflurane concentration in the perfusate for different gas flows. Middle refers to the sample sight between oxygenators 2 and 3. [Color figure can be viewed at wileyonlinelibrary.com]
In general, the measured sevoflurane levels in the perfusate were higher in group B than in group A (Figures 8, 9, 10, 11). When comparing the 2% subgroups, the measured sevoflurane differed significantly between group A and group B (p < 0.01), which was also the case for the 4% subgroups (p < 0.01).
FIGURE 8.
Pilot 2. Group A. 2%. Sevoflurane concentration in perfusate (red) and “expired” air (black) measured by the different gas monitors, for different gas flows. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 9.
Pilot 2. Group A. 4%. Sevoflurane concentration in perfusate (red) and “expired” air (black) measured by the different gas monitors, for different gas flows. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 10.
Pilot 2. Group B. 2%. Sevoflurane concentration in perfusate (red) and “expired” air (black) measured by the different gas monitors, for different gas flows. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 11.
Pilot 2. Group B. 4%. Sevoflurane concentration in perfusate (red) and “expired” air (black) measured by the different gas monitors, for different gas flows. [Color figure can be viewed at wileyonlinelibrary.com]
In group C, an Inspire 8F M oxygenator was used as oxygenator 1 and 2 Maquet Quadrox‐I Neonatal oxygenators were used as oxygenators 2 and 3. Sevoflurane at 4% concentration was administered continuously. A Vamos gas monitor was attached to oxygenator 3 and a Datex gas monitor was attached to oxygenator 2.
A constant gas flow of 0.2 L/min was maintained over oxygenators 1 and 3. For oxygenator 2, gas flows of 0.2, 0.3, 0.4, 0.5, and 0.6 L/min were tested until gas monitors indicated a steady state of sevoflurane, after which perfusate samples were collected. Sevoflurane levels measured in group C are shown in Figure 12. Linear regression analysis demonstrated a moderate correlation between sevoflurane levels in the perfusate and those measured by the Datex gas monitor on oxygenator 2 (r = 0.63), while the correlation with oxygenator 3 was negligible (r = 0.25).
FIGURE 12.
Pilot 2. Group C. Sevoflurane in perfusate and “expired” air for different gas flows. [Color figure can be viewed at wileyonlinelibrary.com]
A very strong correlation was observed between the gas flow in oxygenator 2 and the sevoflurane measured by the Datex gas monitor connected to oxygenator 2 (r = 0.94). This was also the case for the gas flow in oxygenator 2 and the sevoflurane measured by the Vamos gas monitor connected to oxygenator 3 (r = 0.75).
There was a moderate correlation observed between the applied gas flow in oxygenator 2 and the sevoflurane measured in the perfusate (r = 0.59).
3.3. Pilot 3; Comparing Different Sevoflurane Concentrations
In pilot 3, a NMP setup with one oxygenator (see Figure 13), an Inspire 8F M, was tested (n = 8). Sevoflurane was administered at 2% (n = 4) or 4% (n = 4) for the first 90 min with a gas flow of 0.5 L/min. Perfusate samples were collected at 15, 30, 45, 60, 75, 90, 105, and 120 min, and blood gas analyses were performed at baseline, 60 min, and 120 min.
FIGURE 13.
Experimental set‐up pilot 3. (This circuit was not connected to kidneys; the kidneys shown serve illustrative purposes only). [Color figure can be viewed at wileyonlinelibrary.com]
In general, these experiments produced relatively stable results (Figures 14 and 15). In the 2% sevoflurane group, perfusate sevoflurane concentrations remained comparable during the first 90 min (p = 0.86). There were no significant differences in pO2 between experiments (p = 0.37) or over time: baseline (79.53 ± 1.6) vs. 60 min (78.5 ± 2.96, p = 0.8), baseline vs. 120 min (80.85 ± 1.97, p = 0.69), and 60 min vs. 120 min (p = 0.35). Similarly, pH showed no significant differences between experiments (p = 0.39) and remained stable over time: baseline (7.38 ± 0.02) vs. 60 min (7.38 ± 0.01, p = 0.99), baseline vs. 120 min (7.37 ± 0.01, p = 0.49), and 60 min vs. 120 min (p = 0.43). A significant difference in pCO2 was observed (p = 0.01). Changes were significant between baseline (4.8 ± 0.1) and 60 min (4.6 ± 0.04) (p = 0.01), as well as between 60 min and 120 min (4.75 ± 0.05) (p < 0.05). However, the change between baseline and 120 min was not significant (p = 0.65).
FIGURE 14.
Pilot 3. Measured levels of sevoflurane in perfusate and “expired” air. Cet% = end‐tidal concentration as measured by the gas monitor. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 15.
Pilot 3. Measured levels of pO2, pCO2 and pH in the 2% and 4% sevoflurane groups, depicted in means ± standard deviations.
In the 4% sevoflurane group, perfusate sevoflurane concentrations were comparable during the first 90 min (p > 0.99). There were no significant differences in pO2 (p = 0.69) between experiments, and pO2 did not change significantly over time: baseline (76.83 ± 2.41) vs. 60 min (75.8 ± 3.09, p = 0.87), baseline vs. 120 min (77.6 ± 3.16, p = 0.93), or 60 min vs. 120 min (p = 0.67).
A significant difference in pH was observed (p = 0.03), with a notable change between baseline (7.37 ± 0.01) and 120 min (7.35 ± 0.02) (p = 0.03). However, there were no significant differences between 60 min (7.37 ± 0.01) and 120 min (p = 0.07), or between baseline and 60 min (p = 0.89). There was no significant difference in pCO2 (p = 0.1), with no changes noted between baseline (4.66 ± 0.14) and 60 min (4.5 ± 0.13) (p = 0.25), baseline and 120 min (4.72 ± 0.13) (p = 0.80), or between 60 min and 120 min (p = 0.09). After 90 min of perfusion, the vaporizer was closed and in both the 2% and the 4% groups the measured sevoflurane concentrations decreased to almost 0 mg/L within 15 min.
4. Discussion
The objective of this study was to develop a stable porcine kidney NMP setup incorporating sevoflurane administration. Initial experiments showed that directly injecting liquid sevoflurane into the arterial limb was not feasible due to excessive gas formation and unstable concentrations in the venous limb. A bolus injection to prime the system caused gas bubbles to accumulate in the oxygenator and circuit, as 1 mL of liquid sevoflurane vaporizes into approximately 182.7 mL of gas [20]. While small amounts of gas could be removed via a shunt or syringe, the volume was too large for effective removal. The gas was likely sevoflurane, as manipulating the bubbles increased the “expired” sevoflurane concentration in the venous limb. Given that intravascular gas poses a serious risk of organ damage, direct injection of liquid sevoflurane was deemed unsuitable. Additionally, administering volatile anesthetics in this way can cause chemical injury to endothelial cell walls, leading to severe lung damage and mortality in both animal models and humans [21].
To address these issues, alternative sevoflurane administration methods using a vaporizer connected to an oxygenator were explored in subsequent pilot experiments. Various oxygenators were tested due to the lack of data on their sevoflurane exchange capacity. A three‐oxygenator configuration was initially assessed: the presence of sevoflurane at the second oxygenator would confirm effective gas exchange from the first, while measurements at the third oxygenator would evaluate the second's ability to remove sevoflurane from circulation. In all subgroups, sevoflurane was detected at the gas outlet of the second oxygenator, confirming that the first oxygenator successfully facilitated sevoflurane exchange. However, sevoflurane was also detected at the gas monitor connected to the third oxygenator, with some cases (groups A and B) showing even higher concentrations than at the second oxygenator. These conflicting results may be attributed to measurement errors due to water precipitation and filter saturation in the gas lines. Additionally, the oxygenators had been used in prior experiments, raising the possibility of damage to the gas exchange membranes following prolonged exposure to sevoflurane. Similar membrane deterioration has been described in multiple reports for other volatile anesthetics [22, 23, 24, 25].
In group C, increasing gas flow at the second oxygenator did not eliminate sevoflurane from the perfusate, as residual amounts were still detected at the third oxygenator. Interestingly, higher gas flow at the second oxygenator led to decreased sevoflurane levels measured at that site, likely due to reduced residence time resulting in less efficient evaporation. In groups A and B, perfusate sevoflurane concentrations measured between the second and third oxygenators showed that the second oxygenator could remove some sevoflurane, as values were consistently lower than those in the venous limb. However, complete elimination from the perfusate was not achieved with any of the tested oxygenators.
The insights gained from previous experiments guided the design of the final pilot study. A single‐oxygenator setup was chosen due to challenges observed prior, with the Inspire 8F M oxygenator selected for its stable sevoflurane levels and availability of unused units. Using new oxygenators reduced the risk of pre‐existing membrane damage caused by sevoflurane exposure, ensuring comparability across experiments. To further minimize membrane degradation, sevoflurane administration was limited to 90 min. With these precautions, a stable system was established, maintaining consistent sevoflurane levels in both the 2% and 4% groups. Partial oxygen pressure also remained stable, demonstrating that the Inspire 8F M oxygenator effectively oxygenates the perfusate while sustaining a steady‐state sevoflurane concentration. A limitation of our study is the absence of active scavenging; despite the fume hood and the use of a Flurosorb canister (Sedana Medical, Danderyd, Sweden), sevoflurane may have escaped. In future experiments we'll look for strategies to minimize occupational exposure.
5. Conclusion
These pilot experiments confirm the feasibility of designing an NMP circuit for kidney perfusion that allows stable sevoflurane administration while maintaining adequate oxygenation. Among the tested oxygenators, the Inspire 8F M showed the most stable results. Due to potential membrane damage from prolonged sevoflurane exposure, oxygenators used in these setups should not be reused in future experiments. Additionally, gas monitor measurements of sevoflurane concentrations should be interpreted cautiously, as they indicate presence rather than accurate concentration in the perfusate and are not reliable for assessing whether a steady state has been reached.
Author Contributions
Study design: P.N.G., S.Y., R.F.H., P.J.O., M.M.R.F.S., H.G.D.L. and G.J.N.‐M.; experimental conduct: P.N.G., R.S.T., S.J.L., P.J.O. and G.J.N.‐M.; sample and data analysis, and interpretation: P.N.G., S.Y., R.S.T., R.F.H., P.J.O., D.R., M.J., M.M.R.F.S., H.G.D.L. and G.J.N.‐M.; writing and revision of manuscript: P.N.G., S.Y., R.S.T., R.F.H., P.J.O., D.R., M.J., M.M.R.F.S., H.G.D.L. and G.J.N.‐M.; project supervision and acquisition of funding: S.Y. and G.J.N.‐M.; All authors have read and agreed to the published version of the manuscript.
Conflicts of Interest
Matthieu Jaboudon has received consulting fees from Abbvie and fees for lectures from Sedana Medical (Danderyd, Sweden). He has received equipment and materials from General Electrics Healthcare (Chigago, IL, USA) and Sedana Medical. Michel M.R.F. Struys has no conflicts of interest related to this work. In general, his research group/department received (over the last 3 years) research grants and consultancy fees from Masimo (Irvine, CA, USA), Becton Dickinson (Eysins, Switzerland), Fresenius‐Kabi (Bad Homburg, Germany), Paion (Aachen, Germany), Medcaptain Europe (Andelst, The Netherlands), Baxter (Chicago, Il, USA), Eagle Pharmaceuticals Inc (Woodcliff, New Jersey, USA), HanaPharm (Seoul, Republic of Korea). He receives royalties on intellectual property from Demed Medical (Sinaai, Belgium) and the Ghent University (Gent, Belgium). Henri G.D. Leuvenink is Chief Scientific Officer of 34 Lives (West Lafayette, IN, USA) and has received institutional research grants from the Dutch Kidney Foundation and NOVO Nordisk Foundation. Gertrude J. Nieuwenhuijs‐Moeke has received medical research grants from Sedana Medica (Danderyd, Sweden) and Astellas Pharma (Leiden, the Netherlands) and has received research grants from the Dutch Transplant Society, the UMCG Transplant Fund, the European Society of Anaesthesia and Intensive Care, HosmartAI, the De Cock Hadders Foundation and NIAA RCoA/BJA and travel grants from the European Society of Anaesthesia and Intensive Care, University Hospital Zurich and the Scandinavia Society of Anaesthesia and Intensive Care; plus, she is an editor of the British Journal of Anaesthesia Education. The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. The rest of authors have no conflicts of interest related to this work.
Appendix 1.
Pilot 2. The gas flows and administered sevoflurane concentrations.
| Oxygenator 1 (L/min) | Oxygenator 2 (L/min) | Oxygenator 3 (L/min) | Sevoflurane vaporizer (%) | |
|---|---|---|---|---|
| A group | 0.2 | 0.2 | 0.2 | 2 |
| 0.3 | 0.3 | 0.3 | 2 | |
| 0.4 | 0.4 | 0.4 | 2 | |
| 0.5 | 0.5 | 0.5 | 2 | |
| 0.6 | 0.6 | 0.6 | 2 | |
| 0.2 | 0.2 | 0.2 | 4 | |
| 0.3 | 0.3 | 0.3 | 4 | |
| 0.4 | 0.4 | 0.4 | 4 | |
| 0.5 | 0.5 | 0.5 | 4 | |
| 0.6 | 0.6 | 0.6 | 4 | |
| B group | 0.2 | 0.2 | 0.2 | 2 |
| 0.3 | 0.3 | 0.3 | 2 | |
| 0.4 | 0.4 | 0.4 | 2 | |
| 0.5 | 0.5 | 0.5 | 2 | |
| 0.6 | 0.6 | 0.6 | 2 | |
| 0.2 | 0.2 | 0.2 | 4 | |
| 0.3 | 0.3 | 0.3 | 4 | |
| 0.4 | 0.4 | 0.4 | 4 | |
| 0.5 | 0.5 | 0.5 | 4 | |
| 0.6 | 0.6 | 0.6 | 4 | |
| C group | 0.2 | 0.2 | 0.2 | 4 |
| 0.2 | 0.3 | 0.2 | 4 | |
| 0.2 | 0.4 | 0.2 | 4 | |
| 0.2 | 0.5 | 0.2 | 4 | |
| 0.2 | 0.6 | 0.2 | 4 |
Funding: This work was supported by Tekke Huizinga Fonds, STHF/AD 24.004.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.