Loading

International Journal of Clinical Anesthesiology

Overview of Sevoflurane as an Volatile Anesthetic

Mini Review | Open Access
Article DOI :

  • 1. Department of Physiology,Yüksek ?htisas University,Turkey
  • 2. Department of Physiology, Ufuk University, Turkey
+ Show More - Show Less
Corresponding Authors
Aydogan Sami, Department of Physiology,Yüksek ?htisas University, Faculty of Medicine, Ankara, Turkey, Email: aydogansami@gmail.com, aydoganburcumd@gmail.com
INTRODUCTION

Sevoflurane is one of the most widely used inhalation anaesthetic agent for the induction and maintenance of general anesthesia in surgical procedures. Although sevoflurane was synthesized towards the end of the 1960s and used for the first time in 1971, its enterence in clinical use was in the 1990s and its use has become widespread with the completion of clinical studies [1]. It is one of the most commonly used inhalation anesthetics in clinical practice due to the absence of an unpleasant odor, low flammability, little irritation impact to the respiratory tract, and low side effects on organ systems [2]. ?n addition, compared to other inhalation anesthetic agents it has lower blood:gas partition coefficient. Correspondingly, sevoflurane has rapid induction and short recovery time from anesthesia [3].

Physical and Chemical Properties of Sevoflurane

Sevoflurane is an inhalation agent containing fluorine. Fluoromethyl-2,2,2-trifluoro-1-(trifluoromethyl) has been chemically formulated. At room temperature and pressure, sevoflurane is a colorless, and non-explosive liquid. Sevoflurane, such as isoflurane, halothane and enflurane, can be used in classical evaporators due to its high welding point and low vapor pressure [1,4]. Sevoflurane is a powerful breath anesthetic that provides fast induction and control of the depth of anesthesia and causes rapid recovery due to its low solubility [5]. The blood:gas partition coefficient of sevoflurane is 0.69 [3]. The fast compilation feature is provided from the patient’s operation room and intensive care unit after anesthesia to rapid recovery [1]. The vapor pressure of sevoflurane with a MAX value of 2% is 160 mmHg (20o C) and boiling point is 58.6o C [6]. ?t is reported that the minimum alveolar concentration (MAC) of sevoflurane is between 1 .71 % [7] and 2.05% [8]. The MAC for sevoflurane, is similar with other anaesthetics a little higher in children [9].

Metabolism and Biotransformation of Sevoflurane

Sevoflurane, like other fluorinated volatile anesthetics, biotransforms to organic and inorganic fluoride metabolites. Cytochrome p-450 catalyzes the oxidation of sevoflurane [10]. Cytochrome p-450 liver microsomal enzyme (especially the 2E1 isoform) metabolizes sevoflurane at a rate of one-fourth compared to halothane (5% vs. 20%). The primary organic metabolites of sevoflurane are hexafluoroisopropanol (HFIP). HFIP is the only identified organic fluoride metabolite and conjugates rapidly with glucronic acid [11]. Sevoflurane leads to the formation of compounds called Compound A, B, C, D, E, F as a result of a reaction with a carbon dioxide absorber. Compound A has been shown to cause corticomedullary necrosis, which induces renal damage in rats.

The Effect of Sevoflurane on the Respiratory System

Sevoflurane depresses respiratory function dosedependently; this is followed by a slight increase in PaCO2 and minute ventilation [5]. As the depth of anesthesia increases, there is a decrease in the tidal volume-carbon dioxide response curve. It inhibits pulmonary vasocontriction dose-dependent. It does not cause airway irritation and does not stimulate the cough reflex. An advantage of sevoflurane is that it does not stimulate airway irritation and cough reflex in children and thus allows for the induction of inhalation anesthesia [12].

Effect of Sevoflurane on the Cardiovascular System and Hemorheology

A number of volatile anesthetics, such as sevoflurane and nonvolatile anesthetics is known to affect the overall cardiovascular functions and microcirculatory hemodynamics. Sevoflurane depresses myocardial contraction and reduces systemic vascular resistance. This decrease in arterial blood pressure is slightly less than that of isoflurane and desflurane. At high sevoflurane concentrations, blood pressure decreases progressively, as with other inhaled anesthetics [13]. Sevoflurane does not change heart rate. It does not potentiate epinephrineinduced cardiac arhythmias. Although myocardial blood flow decreases, it does not affect myocardial perfusion [14]. It may cause prolongation of the QT [15]. It has been shown to be cardioprotective in patients undergoing cardiac surgery [16,17]. Landoni et al., emphasized that desflurane and sevoflurane reduce mortality and cardiac morbidity in cardiac surgery patients [16].

The rheological properties of blood are also important in maintaining circulatory homeostasis during the conditions of health and disease. To have a knowledge of blood rheology is useful fort he anesthesiologist in most situations. Some alterations in blood rheology during anesthesia have been observed. For example, during cardiopulmonary bypass , dramatic changes in the rheological properties of blood may occur, this changes which can influence the overall perfusion pressure and regional blood distribution and oxygenation [18].

The alteration in the deformability of erythrocytes is one of the main crucial factors that should be taken into account during the surgeries to improve the tissue perfusion including the cerebral perfusion. A number of studies revealed that, sevoflurane does not indicate the hemodynamic side effects that desflurane and the other volatile anesthetics cause [19]. As seen in our prior study on rats in 2006, it shown that the volatile anesthetics, desfluran and sevoflurane impairs the deformability of erythrocytes, especially in aged animals, whereas it had not any significant effect in young ones which may be due to the flexibility of the young erythrocytes leading them to tolerate to the environmental changes [20-22]. This may be due to the alterations in membrane structure with age. These results reveal that the inhalation anesthetics have similar effects on erythrocyte deformability and may cause more serious problems, especialy in the elder people ,during the surgery and anesthesia.

The Effect of Sevoflurane on the Hepatic System

Sevoflurane reduces portal blood flow, but increases hepatic blood flow. Thus, the total hepatic blood flow and oxygen supply are preserved [15]. Drug-dependent liver damage may occur on a spectrum ranging from asymptomatic alanine transaminase elevation due to volatile anesthetics to fatal hepatic necrosis. There are limited studies on modern inhalational anesthetic agents in the literature. It has been reported that drug-dependent liver damage is more common, especially in trauma patients. Again, in this study, no significant difference was found between Decflurane and sevoflurane in terms of causing liver damage [23]. In addition, cases of hepatic damage developed after sevoflurane exposure have been reported in the literature [24,25].

The Effect of Sevoflurane on the Urinary System

Sevofurane reduces renal blood flow [15]. Carbon dioxide absorbent alkalis such as sodalime or barium hydroxide can cause the destruction of sevoflurane, a nephrotoxic component called Compound A can be released. An increase in respiratory gas temperature, low-flow anesthesia, dry barium hydroxide absorbant, high sevoflurane concentration and a long duration of anesthesia may increase Compound A level [15]. According to Gonsowski et al. [26,27], showed that Compound A causes corticomedullary necrosis, which induces renal damage in rats. They found that renal damage was observed when doserelated and compound A concentrations were 50 ppm and above. However, although the long-term effects of sevoflurane are unknown, the renal toxicity effect is controversial. In some studies conducted in humans; renal dysfunction did not occur after anesthesia. Some researchers recommend that fresh gas flow should be at least 2 lt/min for anesthesia that will last longer than a few hours, and sevoflurane should not be used in patients with previous renal dysfunction [10]. The nephrotoxicity potential is associated with an increase in inorganic fluoride. Renal dysfunction was not clinically significant with sevoflurane anesthesia in patients whose serum fluoride concentration exceeded 50 µmol/L during sevoflurane administration (about 7% of patients) [15].

The Effect of Sevoflurane on the Central Nervous System

As with Isoflurane and Desflurane, sevoflurane causes an increase in cerebral blood flow and intracranial pressure in normocapnia, but some studies have shown a decrease in cerebral blood flow. Autoregulation of cerebral blood flow may be impaired at high sevoflurane concentrations. It decreases cerebral metabolic oxygen consumption and it dose not causes seizure activity [15,28]. Sevoflurane also has anti-inflammatory and neuroprotective effects. It has been reported to reduce neurological injury, cerebral infact volume and inflammatory factor levels. A comprehensive understanding of Sevofluran’s neuroprotective effect will help open new I/R treatment ways, enable physicians to make new clinical treatment solutions, and help for effective treatment [29].

The Effect of Sevoflurane on the Neuromuscular System

Sevoflurane depresses the neuromuscular junction. It potentiates the effect of neuromuscular blockers depending on the dose, sensitizes the neuromuscular junction [30]. Sevoflurane provides sufficient muscle relaxation for intubation after inhalation induction in children [15].

REFERENCES
  1. Brown B. Sevoflurane: Introduction and Overview. Anesth Analg. 1995; 1: 1S-3S.
  2. Delgado?Herrera L, Ostroff RD, Rogers SA. Sevoflurane: Approaching the Ideal Inhalational Anesthetic A Pharmacologic, Pharmacoeconomic, and Clinical Review. CNS Drug Rev. 2001; 7: 48- 120.
  3. Strum DP, Eger EI 2nd, “Partition coefficients for sevoflurane in human blood, saline, and olive oil. Anesth Analg. 1987; 66: 654-656.
  4. Bedi A, Howard Fee JP. Inhalational anaesthesia. Curr Opin Anaesthesiol. 2001; 14: 387-392.
  5. Green WB, Jr. The ventilatory effects of sevoflurane. Anesth Analg.1995; 81: 23-26.
  6. Eger EI. New inhaled anesthetics. Anesthesiol. 1994; 80: 906-922.
  7. Kharasch ED, Armstrong AS, Gunn K, Artru A, Cox K, Karol MD. Clinical sevoflurane metabolism and disposition.II. The role of cytochrome P450 2E1 in fluoride and hexafluroisopropanol formation. Anesthesiol. 1995; 82: 1379-1388.
  8. Scheller MS, Saidman LJ, Partridge BL. MAC of sevoflurane in humans and the New Zealand white rabbit. Can J Anaesth. 1988; 35: 153-156.
  9. Lerman J, Sikich N, Kleinman S, Yentis S. The pharmacology of sevoflurane in infants and children. Anesthesiol. 1994; 80: 814-824.
  10. Kharasch ED. Biotransformation of sevoflurane. Anesth Analg. 1995; 81: 27-38.
  11. Schindler E, Hempelmann G. Perfusion and metabolism of liver and splanchnic nerve area under sevoflurane anesthesia. Anaesthesist. 1998; 47: S19-23
  12. Lerman J. Sevoflurane in pediatric anesthesia. Anesth Analg. 1995; 81: 4-10.
  13. Ebert TJ, Harkin CP, Muzi M. Cardiovascular responses to sevoflurane: a review. Anesth Analg. 1995; 81: S11-22.
  14. Bulte CS, Slikkerveer J, Kamp O, Heymans MW, Loer SA, de Marchi SF. ve di?erleri. General anesthesia with sevoflurane decreases myocardial blood volume and hyperemic blood flow in healthy humans. Anesth Analg. 2013; 116: 767-774.
  15. John F. Butterwoth DCM, John D. Wasnick. Inhalation anesthetics. G. E. Morgan & M. S. Mikhail (Ed.). Clinical anesthesiology, 153-173). New York: Lange Medical Books/McGraw Hill, Medical Pub. Division, 2013.
  16. Landoni G, Biondi-Zoccai GG, Zangrillo A, Bignami E, D’Avolio S, Marchetti C, et al. Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomized clinical trials. J Cardiothorac Vasc Anesth. 2007; 21: 502-511.
  17. Landoni, G., Fochi, O., Tritapepe, L., Guarracino, F., Belloni, I., Bignami, E. ve di?erleri. Cardiac protection by volatile anesthetics. A review. Minerva Anestesiol. 2009; 75: 269-273.
  18. Aydogan B and Aydogan S. Anesthetics and red blood cell rheology, Korea-Australia Rheology J. 2014; 26: 205-208.
  19. Bedforth NM, Hardman JG, Nathanson MH. Cerebral hemodynamic response to the introduction of desflurane: A comparison with sevoflurane. Anesth Analg. 2000; 91: 152-155.
  20. Aydogan S, Yerer MB, Çomu FM, Arslan M. The influence of sevoflurane anesthesia on the rat red blood cell deformability, Clinical Hemorheol Microc?rcul. 2006; 35: 297-300.
  21. Yerer MB, Aydo?an S, Çomu FM. Gender-related alterations in erythrocyte mechanical activities under desflurane or sevoflurane anesthesia. Clin Hemorheol Microcirc. 2008; 39: 423-427.
  22. Yerer MB, Aydogan S, Çomu FM, et al.,The red blood cell deformability alterations under desfluran anesthesia in rats. Clinical Hemorheol and Microc?rcul. 2006; 35: 213-216.
  23. Lin J, Moore D, Hockey B, Di Lernia R, Gorelik A, Liew D. ve di?erleri. Drug-induced hepatotoxicity: incidence of abnormal liver function tests consistent with volatile anaesthetic hepatitis in trauma patients. Liver Int. 2014; 34: 576-582.
  24. Shichinohe Y, Masuda Y, Takahashi H, Kotaki M, Omote T, Shichinohe M. ve di?erleri. A case of postoperative hepatic injury after sevoflurane anesthesia. Masui. 1992; 41: 1802-1805.
  25. Zizek D, Ribnikar M, Zizek, B, Ferlan-Marolt V. Fatal subacute liver failure after repeated administration of sevoflurane anaesthesia. Eur J Gastroenterol Hepatol. 2010; 22: 112-115.
  26. Gonsowski CT, Laster MJ, Eger EI, 2nd, Ferrell LD, Kerschmann RL. Toxicity of compound A in rats. Effect of a 3-hour administration. Anesthesiol. 1994; 80: 556-565.
  27. Gonsowski CT, Laster MJ, Eger EI, 2nd, Ferrell LD, Kerschmann RL. Toxicity of compound A in rats. Effect of increasing duration of administration. Anesthesiol. 1994; 80: 566-573.
  28. Ebert TJ, Muzi M, Lopatka CW. Neurocirculatory responses to sevoflurane in humans. A comparison to desflurane. Anesthesiology. 1995; 83: 88- 95.
  29. Tian-Yu Liang, Song-Yang Peng, Mian Ma, Hai-Ying Li, Zhong Wang, Gang Chen. Protective effects of sevoflurane in cerebral ischemia reperfusion injury: a narrative review. Med Gas Res. 2021; 11: 152- 154.
  30. Morita T, Kurasaki D, Tukagoshi H, Sugaya T, Saito S, Sato S, et al. Sevoflurane and isoflurane impair edrophonium reversal of vecuronium-Induced neuromuscular block. Can J Anaesth. 1996; 43: 709-805.
Received : 17 Apr 2023
Accepted : 13 Apr 2023
Published : 15 Apr 2023
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X