Sevoflurane has been shown to be safe and effective when administered concurrently with a wide variety of agents commonly encountered in surgical such as, CNS agents, autonomic drugs, skeletal muscle relaxants, anti-infective agents including aminoglycosides, hormones and synthetic substitutes, blood derivatives and cardiovascular drugs, including epinephrine.
Barbiturates: Sevoflurane administration is compatible with barbiturates as commonly used in surgical practice.
Benzodiazepines and Opioids: Benzodiazepines and opioids are expected to decrease the MAC of sevoflurane in the same manner as with other inhalational anesthetics. Sevoflurane administration is compatible with benzodiazepines and opioids as commonly used in surgical practice.
Inducers of CYP2E1: Medicinal products and compounds that increase the activity of CYP450 isoenzyme CYP2E1 such as isoniazid and alcohol, may increase the metabolism of sevoflurane and lead to significant increases in plasma fluoride concentrations (see Pharmacology: Pharmacokinetics under Actions).
Nitrous Oxide: As with other halogenated volatile anesthetics, the MAC of sevoflurane is decreased when administered in combination with nitrous oxide. The MAC equivalent is reduced approximately 50% in adult and approximately 25% in pediatric patients (see Dosage & Administration).
Neuromuscular Blocking Agents: As with other inhalational anesthetic agents, sevoflurane affects both the intensity and duration of neuromuscular blockade by nondepolarizing muscle relaxants. When used to supplement alfentanil-N2O anesthesia, sevoflurane potentiates neuromuscular block induced with pancuronium, vecuronium or atracurium. The dosage adjustments for these muscle relaxants when administered with sevoflurane are similar to those required with isoflurane. The effect of sevoflurane on succinylcholine and the duration of depolarizing neuromuscular blockade has not been studied.
Dosage reduction of neuromuscular blocking agents during induction of anesthesia may result in delayed onset of conditions suitable for endotracheal intubation or inadequate muscle relaxation because potentiation of neuromuscular blocking agents is observed a few minutes after the beginning of sevoflurane administration.
Among nondepolarizing agents, vecuronium, pancuronium and atracurium interactions have been studied. In the absence of specific guidelines: (1) for endotracheal intubation, do not reduce the dose of nondepolarizing muscle relaxants; and, (2) during maintenance of anesthesia, the dose of nondepolarizing muscle relaxants is likely to be reduced compared to that during N2O/opioid anesthesia. Administration of supplemental doses of muscle relaxants should be guided by the response to nerve stimulation.