High quantities: Evaluating the association between cannabis use and propofol anesthesia during endoscopy

BACKGROUND

Endoscopy under propofol sedation has become a routine procedure. Given the number of Canadians undergoing an endoscopy annually, as well as the pervasive use of cannabis by many patients, understanding the effect of cannabis use on the propofol dose at endoscopy is highly relevant. We aimed to evaluate the association between cannabis exposure and the propofol dose needed to achieve adequate sedation at endoscopy.

METHODS

A case-control study of individuals undergoing endoscopy was conducted at a single outpatient endoscopy clinic in London, Ontario between 2014 and 2017. Cases included all individuals with any self-reported cannabis exposure, while controls included all individuals without any self-reported history of cannabis use. Dose of propofol administered by a single anesthetist was collected on each subject as well as additional demographic and procedure-related covariates.

RESULTS

Three hundred and eighteen participants were included (cases, n = 151; controls, n = 167). Cannabis exposure was associated with an increase in propofol dose (cases 0.33 mg/kg/minute ±0.24; controls, 0.18 mg/kg/minute ±0.11; p<0.0001). Cannabis exposure remained an independent predictor of propofol dose on multivariate linear regression accounting for other important covariates (p<0.0001). Daily cannabis users required a higher propofol dose than weekly or monthly users. Three procedural sedation-related complications occurred in the cannabis-exposed group, while none occurred in the unexposed group.

CONCLUSION

Our data suggest that cannabis use is significantly associated with the quantity of propofol needed for sedation at endoscopy. Further study is needed to better understand the molecular basis for this possible drug-drug interaction.

Evaluation of pediatric procedural sedation education in pediatric emergency medicine fellowships

ABSTRACT

Pediatric procedural sedation (PPS) is often performed outside of the operating room, and by various sub-specialty providers. There is no consistency in how pediatric emergency medicine (PEM) fellows are trained in PPS. The objective of this study was to survey PEM program directors (PDs) and PEM fellows about their current sedation teaching practices via a direct survey. While many fellowship programs train PEM fellows in PPS, we hypothesize that there is no consistent method of developing and measuring this skill.A 12-question survey was sent to PEM PDs directly via email. A separate 17-question survey was sent to current PEM fellows via their program coordinators by email. Each survey had multiple choice, yes-no and select-all program questions. Responses were collected in an online (REDCap) database and summarized as frequencies and percentages.Based on identifiable email, 67 programs were contacted, with a PD response rate of 46 (59%). Sixty-two program coordinators were contacted based on identifiable email with 78 fellow responses. We noted that 11/46 PD respondents offer a formal PPS rotation. Thirty programs report using propofol in the emergency department and 93% of PD respondents (28/30) actively train fellows in the use of propofol. Approximately 62% of PEM fellow respondents (48/78) report sedating without any attending oversight. Twenty-eight percent of PEM fellow respondents report using simulation as a component of their sedation training.PPS is a critical skill. However, there is a lack of consistency in both education and evaluation of competency in this area. An organized PPS rotation would improve PPS case exposure and PPS skills.

Propofol Safety in Anticoagulated and Nonanticoagulated Patients During Extracorporeal Membrane Oxygenation

Sedation management during extracorporeal membrane oxygenation(ECMO) is a common challenge encountered by treating intensivists. Data about the safety of propofol use during ECMO has been contradictory. We aimed to investigate associated risks of propofol use on oxygenator lifespan and to explore the effect of propofol use on oxygenator membranes when therapeutic anticoagulation was omitted. Adult respiratory ECMO patients who received propofol were retrospectively compared with those who did not, and outcomes were assessed by means of duration of oxygenator functionality before requiring an exchange, and number of exchanges during propofol use and/or ECMO support. Out of the 63patients included in the analysis, 46%received propofol during ECMO as part of sedation regimen. The use of propofol was not found to be associated with an increased incidence of oxygenator failure when compared with cohorts who did not receive propofol (21% propofol arm vs. 6% control, p = 0.13). When analyzed for anticoagulation omission effects, propofol did not increase the risk of oxygenator failure (p = 0.63). The only predictor that statistically predicted the risk of oxygenator failure was development of heparin-induced thrombocytopenia (HIT) during ECMO. The results of this study further support the previously reported safety of propofol utilization during respiratory ECMO even in the absence of anticoagulation.

Bispectral index monitoring of the clinical effects of propofol closed-loop target-controlled infusion: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

To investigate whether closed-loop systems under bispectral index anesthesia depth monitoring can reduce the intraoperative propofol dosage.

METHODS

All randomized controlled trials (RCTs) on reducing propofol dosage under closed-loop systems were collected, and the literature was screened out, the abstracts and full texts were carefully read, and the references were tracked, data extraction and quality evaluation were conducted on the included research, and the RevMan5.3 software was used for meta-analysis. The main results were propofol and the incidence of adverse reactions such as hypertensive hypotension and postoperative cognitive dysfunction. A total of 879 cases were included in 8 articles, including 450 occurrences in the closed-loop system group and 429 cases in the open-loop system group.

RESULTS

Compared with manual control, closed-loop systems under bispectral index anesthesia depth monitoring reduced the dose of propofol (MD: -0.62, 95% CI: -1.08--0.16, P = .008), with heterogeneity (I2 = 80%). Closed-loop systems significantly reduced the incidence of abnormal blood pressure (MD: -0.02, 95%CI: -0.05-0.01, P = .15, I2 = 74%) and postoperative cognitive dysfunction (MD: -0.08, 95% CI: -0.14 -0.01, P = .02, I2 = 94%).

CONCLUSION

Bispectral index monitoring of propofol closed-loop target-controlled infusion system can reduce the amount of propofol, reduce the incidence of adverse reactions such as hypertensive or hypotension and postoperative cognitive dysfunction.

Diagnostic Value of Peripheral Blood miR-148a-3p in Patients with Liver Injury After Hepatectomy Under General Anesthesia with Propofol

BACKGROUND

The current study aims to evaluate the correlation between peripheral blood miR-148a-3p level in patients with liver injury after hepatectomy under general anesthesia with propofol, thereby evaluating whether circulating miR-148a-3p can be used as a biomarker of liver injury after hepatectomy.

METHODS

One hundred one patients who underwent hepatectomy at the Fourth Hospital of Xi'an were selected. On the first day after operation, peripheral blood was taken to determine the level of miR-148a-3p in peripheral blood. The correlation between circulating miR-148a-3p and liver injury after operation was analyzed using Pearson's correlation assay.

RESULTS

First, our data showed that the level of miR-148a-3p was increased in the peripheral blood of patients after hepatectomy. The amount of bleeding was significantly correlated with the increase of ALT, AST, and miR-148a-3p. Moreover, the level of miR-148a-3p was significantly correlated with alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Further analysis showed that intraoperative propofol dosage was correlated with ALT, AST, and miR-148a-3p after hepatectomy.

CONCLUSIONS

MiR-148a-3p may be sensitive to ischemic and traumatic liver injury and may be a marker of liver injury after hepatectomy under general anesthesia with propofol.

Comparison of dexmedetomidine-propofol and ketamine-propofol administration during sedation-guided upper gastrointestinal system endoscopy

BACKGROUND

Dexmedetomidine and ketamine popular sedative agents that result in minimal respiratory depression and the presence of analgesic activity. We aimed to compare the effectiveness and safety of a dexmedetomidine-propofol combination and a ketamine-propofol combination during upper gastrointestinal system endoscopy.

METHODS

The study commenced after receiving approval from the local ethics committee. Patients between 18 and 60 years in the American Society of Anesthesiologists (ASA) I and II groups were included. Patients who had severe organ disease, who had allergies to the study drugs, and who refused to participate were excluded. Cases were randomized into a dexmedetomidine-propofol group (Group D, n = 30) and a ketamine-propofol group (Group K, n = 30). Cardiac monitoring, peripheral oxygen saturation, and bispectral index (BIS) monitoring were performed. Group D received 1 mg/kg dexmedetomidine + 0.5 mg/kg propofol intravenous (IV) bolus, 0.5 μg/kg/h dexmedetomidine + 0.5 mg/kg/h propfol infusion. Group K received 1 mg/kg ketamine + 0.125 mL/kg propofol iv bolus, 0.25 mg/kg/h ketamine + 0.125 mL/kg/h propfol infusion. Patients were followed up with a Ramsay Sedation Scale (RSS) of ≥4. Means, standard deviations, lowest and highest frequency values, and ratio values were used for descriptive statistics, and the SPSS 22.0 program was used for statistical analyses.

RESULTS

In Group K, recovery time and mean blood pressure (MBP) values were significantly shorter. Furthermore, coughing rate, pulse, and BIS values were higher than in Group D (P < .05). Although there were no significant differences between the groups in terms of endoscopic tolerance and endoscopist satisfaction, we observed that the dexmedetomidine group experienced more comfortable levels of sedation.

CONCLUSION

Dexmedetomidine-propofol and ketamine-propofol combinations may be suitable and safe for endoscopy sedation due to their different properties. It was observed that the dexmedetomidine-propfol combination was superior in terms of sedation depth and that the ketamine-propofol combination was superior in terms of early recovery. As a result, we suggest the dexmedetomidine-propofol combination for upper gastrointestinal system endoscopy sedation due to hemodynamic stability and minimal adverse effects.

Evaluation of the efficiency of propofol versus isoflurane anesthesia interventions in treating elderly patients with postoperative cognitive dysfunction: A protocol for systematic review and meta-analysis

BACKGROUND

The aim of this study was to systematically evaluate the efficiency of propofol versus isoflurane anesthesia interventions in treating elderly patients with postoperative cognitive dysfunction.

METHODS

We performed an in-depth search in the PubMed, EMBASE, Cochrane Library, Chongqing VIP, WanFang, China National Knowledge Infrastructure, and SinoMed. Additionally, we reviewed the reference lists of included studies. Two independent authors examined the quality of the study and the quality of the extracted data. Regarding the dichotomous outcomes, we stated the results as relative risk, with 95% confidence intervals. We further expressed incessant outcomes as mean difference with a confidence level of 95%.

RESULTS

The findings of the study will be published in a peer-reviewed journal.

CONCLUSION

Findings of this study will help in providing insight to establish if propofol is a suitable intervention to treat postoperative cognitive dysfunction in elderly patients.

SYSTEMATIC REVIEW REGISTRATION NUMBER

INPLASY202090042.

Syringe or mask? Loop electrosurgical excision procedure under local or general anesthesia: a randomized trial

BACKGROUND

Loop electrosurgical excision procedure may be performed under local anesthesia or general anesthesia, and practice patterns differ worldwide. No randomized head-to-head comparison has been published to confirm or refute either practice.

OBJECTIVE

This study aimed to compare loop electrosurgical excision procedure under local anesthesia vs general anesthesia regarding patient satisfaction and procedure-related outcomes such as rates of involved margins, complications, pain, and blood loss.

STUDY DESIGN

Consecutive women referred to our colposcopy unit were recruited. Loop electrosurgical excision procedure was performed under local anesthesia with 4 intracervical injections of bupivacaine hydrochloride 0.5% or under general anesthesia with fentanyl, propofol, and a laryngeal mask with sevoflurane maintenance. The primary endpoint was patient satisfaction assessed on the day of surgery and 14 days thereafter using a Likert scale (score 0-100) and a questionnaire. Secondary endpoints included rates of involved margins, procedure-related complications, pain, blood loss, and surgeon preference. Results were compared using nonparametric and chi-square tests.

RESULTS

Between July 2018 and February 2020, we randomized 208 women, 108 in the local anesthesia arm and 100 in the general anesthesia arm. In the intention-to-treat analysis, patient satisfaction did not differ between the study groups directly after surgery (Likert scale 100 [90-100] vs 100 [90-100]; P=.077) and 14 days thereafter (Likert scale 100 [80-100] vs 100 [90-100]; P=.079). In the per-protocol analysis, women in the local anesthesia arm had significantly smaller cone volumes (1.11 cm³ [0.70-1.83] vs 1.58 cm³ [1.08-2.69], respectively; P<.001), less intraoperative blood loss (Δhemoglobin, 0.2 g/dL [-0.1 to 0.4] vs 0.5 g/dL [0.2-0.9]; P<.001), and higher satisfaction after 14 days (100 [90-100] vs 100 [80-100]; P=.026), whereas surgeon preference favored general anesthesia (90 [79-100] vs 100 [90-100], respectively; P=.001). All other secondary outcomes did not differ between groups (resection margin status R1, 6.6% vs 2.1% [P=.26]; cone fragmentation, 12.1% vs 6.3% [P=.27]; procedure duration, 151.5 seconds [120-219.5] vs 180 seconds [117-241.5] [P=.34]; time to complete hemostasis, 60 seconds [34-97] vs 70 seconds [48.25-122.25] [P=.08]; complication rate, 3.3% vs 1.1% [P=.59]). In a multivariate analysis, parity (P=.03), type of transformation zone (P=.03), and cone volume (P=.02) and not study group assignment, age, body mass index, and degree of dysplasia independently influenced the primary endpoint.

CONCLUSION

Loop electrosurgical excision procedure under local anesthesia is equally well tolerated and offers patient-reported and procedure-related benefits over general anesthesia, supporting the preferred practice in some institutions and refuting the preferred practice in others.

Effects of propofol on intracranial pressure and prognosis in patients with severe brain diseases undergoing endotracheal suctioning

BACKGROUND

To investigate whether the administration of intravenous propofol before endotracheal suctioning (ES) in patients with severe brain disease can reduce the sputum suction response, improve prognosis, and accelerate recovery.

METHODS

A total of 208 severe brain disease patients after craniocerebral surgery were enrolled in the study. The subjects were randomly assigned to the experimental group (n = 104) and the control group (n = 104). The experimental group was given intravenous propofol (10 ml propofol with 1 ml 2% lidocaine), 0.5-1 mg/kg, before ES, while the control group was subjected to ES only. Changes in vital signs, sputum suction effect, the fluctuation range of intracranial pressure (ICP) before and after ES, choking cough response, short-term complications, length of stay, and hospitalization cost were evaluated. Additionally, the Glasgow Outcome Scale (GOS) prognosis score was obtained at 6 months after the operation.

RESULTS

At the baseline, the characteristics of the two groups were comparable (P > 0.05). The increase of systolic blood pressure after ES was higher in the control group than in the experimental group (P < 0.05). The average peak value of ICP in the experimental group during the suctioning (15.57 ± 12.31 mmHg) was lower than in the control group (18.24 ± 8.99 mmHg; P < 0.05). The percentage of patients experiencing cough reaction- during suctioning in the experimental group was lower than in the control group (P < 0.05), and the fluctuation range of ICP was increased (P < 0.0001). The effect of ES was achieved in both groups. The incidence of short-term complications in the two groups was comparable (P > 0.05). At 6 months after the surgery, the GOS scores were significantly higher in the experimental than in the control group (4-5 points, 51.54% vs. 32.64%; 1-3 points, 48.46% vs. 67.36%; P < 0.05). There was no significant difference in the length of stay and hospitalization cost between the two groups.

CONCLUSIONS

Propofol sedation before ES could reduce choking cough response and intracranial hypertension response. The use of propofol was safe and improved the long-term prognosis. The study was registered in the Chinese Clinical Trial Registry on May 16, 2015 (ChiCTR-IOR-15006441).

Anesthetic Management of Awake Craniotomy for Resection of the Language and Motor Cortex Vascular Malformations

BACKGROUND

Although the safety and feasibility of awake craniotomy are well established for epilepsy and brain tumor surgery, its application for resection of vascular lesions, including arteriovenous malformations (AVMs) and cavernomas, is still limited. Apart from the usual challenges of awake craniotomy, vascular lesions pose several additional problems. Our goal is to determine the safety and practicality of awake craniotomy in patients with cerebral vascular malformations located near the eloquent areas, using a refined anesthetic protocol.

METHODS

A retrospective case series was performed on 7 patients who underwent awake craniotomy for resection of AVMs or cavernomas located in the eloquent language and motor areas. Our protocol consisted of achieving deep sedation, without a definitive airway, using a combination of propofol, dexmedetomidine, and remifentanil/fentanyl during scalp block placement and surgical exposure, then transitioning to a wakeful state during the resection.

RESULTS

Six patients had intracranial AVMs, and 1 patient had a cavernoma. Six patients had complete resection; however, 1 patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous awake neurologic and neurophysiologic testing without significant perioperative complications or the need to convert to general anesthesia with a definitive airway.

CONCLUSIONS

Awake craniotomy for excision of intracranial vascular malformations located near the eloquent areas, in carefully selected patients, can facilitate resection by allowing close neuromonitoring and direct functional assessment. A balanced combination of sedative and analgesic medications can provide both adequate sedation and rapid wakeup, facilitating the necessary patient interaction and tolerance of the procedure.

Anesthetic efficacy of propofol combined butorphanol in laparoscopic surgery for ectopic pregnancy: A protocol of systematic review and meta-analysis

BACKGROUND

Recent studies have suggested that propofol combined butorphanol (PB) has anesthetic effect in laparoscopic surgery (LS) for ectopic pregnancy (EP). But investigations of its potential effects are inconsistent. We will explore the current literature examining PB in LS for EP.

METHODS

We will perform a comprehensive search from MEDLINE, Embase, Cochrane Library, PsycINFO, Global Health, Web of Science, Allied and Complementary Medicine Database, and China National Knowledge Infrastructure from inception to the present. Other literatures, such as conference abstracts, references to the relevant reviews will also be checked. Two authors will check the titles, abstracts, and full texts independently. They will also independently carry out data collection and study quality assessment. We will conduct statistical analysis using RevMan 5.3 software.

RESULTS

This study will provide accurate results on the anesthetic effect and safety of PB in LS for EP.

CONCLUSION

This study will establish high-quality evidence of the anesthetic effect and safety of PB in LS for EP to facilitate the clinical practice and guideline development.

STUDY REGISTRATION NUMBER

INPLASY202040044.

Comparison between total intravenous anesthesia and balanced anesthesia on postoperative opioid consumption in patients who underwent laparoscopic-assisted distal gastrectomy

Remifentanil is the most frequently prescribed opioid for total intravenous anesthesia (TIVA) or balanced anesthesia (BA), due to its favorable pharmacological properties. However, several studies have reported opioid-induced hyperalgesia and/or acute tolerance after intraoperatively using remifentanil. In addition, it is imperative to control postoperative pain with lower doses of opioid anesthetic agents. Therefore, we compared the amount of opioid consumption between TIVA with propofol-remifentanil and BA with desflurane-remifentanil, to control postoperative pain in patients who underwent laparoscopic-assisted distal gastrectomy (LADG) with gastroduodenostomy.We retrospectively evaluated demographic variables (age, gender, height, weight, and smoking habits), the duration of general anesthesia (GA), and intraoperatively administered remifentanil consumption through the electronic medical records of patients who underwent LADG with gastroduodenostomy due to early stomach cancer. The primary outcome was postoperative opioid consumption during postoperative day (POD) 2. The secondary outcomes were the incidence of any rescue opioid analgesics administered, numeric rating scale, and various adverse effects during POD 2. We categorized the data in 2 patient groups to compare TIVA with propofol-remifentanil (TIVA group) to BA with desflurane-remifentanil (BA group) on the postoperative opioid analgesic consumption.We divided 114 patients into the TIVA (46 patients) and BA (68 patients) groups. Opioid consumption as a primary outcome was significantly higher in the BA group than in the TIVA group during POD 2 except in the post-anesthesia care unit. The cumulative opioid consumption was significantly higher in the BA than in the TIVA group. The incidence of rescue analgesic at POD 2 was higher in the BA than in the TIVA group. In the TIVA group, remifentanil consumption was higher, and the duration of GA was shorter than that in the BA group. No statistically significant differences were observed when comparing other variables.Our results indicated that the maintenance of GA with TIVA (propofol-remifentanil) reduces opioid consumption for postoperative pain control compared to BA (desflurane-remifentanil) in patients undergoing LADG with gastroduodenostomy.

Pressure support ventilation-pro decreases propofol consumption and improves postoperative oxygenation index compared with pressure-controlled ventilation in children undergoing ambulatory surgery: a randomized controlled trial

PURPOSE

The PSVPro mode is increasingly being used for surgeries under laryngeal mask airway owing to improved ventilator-patient synchrony and decreased work of breathing. We hypothesized that PSVPro ventilation mode would reduce consumption of anesthetic agents compared with pressure control ventilation (PCV).

METHODS

Seventy children between three and eight years of age undergoing elective lower abdominal and urological surgery were randomized into PCV group (n = 35) or PSVPro group (n = 35). General anesthesia was induced with sevoflurane and a Proseal LMA™ was inserted. Anesthesia was maintained with propofol infusion to maintain the entropy values between 40 and 60. In the PCV mode, the inspiratory pressure was adjusted to obtain an expiratory tidal volume of 8 mL·kg-1 and a respiratory rate of 12-20/min. In the PSVPRO group, the flow trigger was set at 0.4 L·min-1 and pressure support was adjusted to obtain expiratory tidal volume of 8 mL·kg-1. Consumption of anesthetic agent was recorded as the primary outcome. Emergence time and discharge time were recorded as secondary outcomes.

RESULTS

The PSVPro group showed significant reduction in propofol consumption compared with the PCV group (mean difference, 33.3 µg-1·kg-1·min-1; 95% confidence interval [CI], 24.2 to 42.2). There was decrease in the emergence time in the PSVPro group compared with the PCV group (mean difference, 3.5 min; 95% CI, 2.8 to 4.2) and in time to achieve modified Aldrete score > 9 (mean difference, 3.6 min; 95% CI, 1.9 to 5.2).

CONCLUSION

The PSVPro mode decreases propofol consumption and emergence time, and improves oxygenation index in children undergoing ambulatory surgery.

TRIAL REGISTRATION

Clinical Trial Registry of India (CTRI/2017/12/010942); registered 21 December, 2017.

Effects of different doses of propofol on the growth and expression of PCNA, CD34 and pAKT proteins in xenografted tumor of BALB/C mice with liver cancer

OBJECTIVE

To observe the effects of different doses of propofol on the growth of transplanted liver tumor in BALB/C mice and check the expression of PCNA, CD34 and pAKT proteins to clarify the mechanism on molecule level.

METHOD

Human primary liver cancer cells SMMC-7721 were subcutaneously cultured in BALB/C mice, and the transplanted tumor model of BALB/C mice was constructed. Forty mice successfully modeled were randomly divided into 5 groups (n = 8): the blank control group (group C), low-fat milk group (group I), low-dose (50 mg/kg) propofol group (P1), middle-dose (100 mg/kg) propofol group (P2) and high dose (150 mg/kg) propofol group (P3). Tumor volume changes were observed at 3, 6, 9, 12, 15 and 18 days (T1, T2, T3, T4, T5, T6 and T7) before and after administration of the drug, and tumor growth curves were plotted. After 19 days of administration, all mice were killed for tumor collection, tumor weight was measured, and the tumor inhibition rate of propofol was calculated. The protein expression of cluster of differentiation 34 (CD34) in transplanted tumor was detected by immunohistochemistry, and the protein expression of proliferating cell nuclear antigen (PCNA) and phospho-Akt (pAKT) was detected by immunofluorescence.

RESULTS

Compared with group C, there was no significant difference in tumor volume in group I. At T2 ~ 7, the tumor volume of group P1, P2 and P3 decreased successively (P < 0.05). There was no significant difference in the inhibitory rate of tumor in group I, and the inhibitory rate of tumor in group P1, P2 and P3 increased successively (P < 0.05). There was no significant difference in PCNA, CD34, and pAKT protein expression in group I, while PCNA, CD34, and pAKT protein content in P1, P2, P3 groups were successively decreased (P < 0.05).

CONCLUSION

Propofol had a dose-dependent effect on the growth of liver cancer xenografts in mice, inhibiting the expression of PCNA, CD34 and pAKT proteins, and the effect was most obvious in the 150 mg/kg propofol group.

Propofol-based intravenous anesthesia is associated with better survival than desflurane anesthesia in pancreatic cancer surgery

BACKGROUND

Previous researches have shown that anesthetic techniques can influence the patient outcomes of cancer surgery. Here, we studied the relationship between type of anesthetic and patient outcomes following elective, open pancreatic cancer surgery.

METHODS

This was a retrospective cohort study of patients who received elective, open pancreatic cancer surgery between January 2005 and July 2018. Patients were grouped according to the anesthesia they received, namely desflurane or propofol. A Kaplan-Meier analysis was conducted, and survival curves were presented from the date of surgery to death. Univariable and multivariable Cox regression models were used to compare hazard ratios for death after propensity matching. Subgroup analyses were performed for all-cause mortality, cancer-specific mortality, and disease progression.

RESULTS

A total of 68 patients (56 deaths, 82.0%) under desflurane anesthesia, and 72 patients (43 deaths, 60.0%) under propofol anesthesia were included. Fifty-eight patients remained in each group after propensity matching. The propofol anesthesia was associated with improved survival (hazard ratio, 0.65; 95% confidence interval, 0.42-0.99; P = 0.047) in the matched analysis. Subgroup analyses showed significantly better cancer-specific survival (hazard ratio, 0.63; 95% confidence interval, 0.40-0.97; P = 0.037) in the propofol group. Additionally, patients under propofol had less postoperative recurrence, but not fewer postoperative metastases formation, than those under desflurane (hazard ratio, 0.55; 95% confidence interval, 0.34-0.90; P = 0.028) in the matched analysis.

CONCLUSIONS

In a limited sample size, we observed that propofol anesthesia was associated with improved survival in open pancreatic cancer surgery compared with desflurane anesthesia. Further investigations are needed to inspect the influences of propofol anesthesia on patient outcomes of pancreatic cancer surgery.

Propofol versus Fentanyl for Sedation in Pediatric Bronchoscopy: A Randomized Controlled Trial

OBJECTIVE

To compare propofol and fentanyl to induce conscious sedation in children undergoing flexible bronchoscopy.

STUDY DESIGN

Randomized controlled trial.

SETTING

Pediatric Pulmonology division at a tertiary care center in Delhi, India.

PARTICIPANTS

Children aged 3-15 years who underwent flexible bronchoscopy.

INTERVENTION

Children received either intravenous propofol 1 mg/kg administered as a slow bolus over 1 minute followed by 2 mg/kg/hour infusion, or intravenous Fentanyl 2 µg/kg administered as a slow bolus over one minute.

OUTCOMES

Primary outcome was time to achieve conscious sedation (Ramsay score 3). Secondary outcomes were need for adjuvant midazolam, physician satisfaction, level of cough, recovery features, and side-effects in the groups.

RESULTS

53 children (propofol 27, fentanyl 26) were enrolled in the study. The mean (SD) time taken to achieve Ramsay score 03 was lower in propofol than fentanyl [15.7 (4.4) s vs 206 (55) s, P<0.001]. Propofol arm had significantly higher physician satisfaction, less requirement of adjuvant midazolam, less coughing and faster regain of full consciousness. There was no difference in drug side-effects between the groups.

CONCLUSIONS

Propofol has a shorter sedation induction time, less coughing during procedure, less recovery time, and better physician satisfaction compared to fentanyl for flexible bronchoscopy in children.

Propofol-based total intravenous anesthesia did not improve survival compared to desflurane anesthesia in breast cancer surgery

BACKGROUND

Breast cancer is the most common cancer in women and several perioperative factors may account for tumor recurrence and metastasis. The anesthetic agents employed during cancer surgery might play a crucial role in cancer cell survival and patient outcomes. We conducted a retrospective cohort study to investigate the relationship between the type of anesthesia and overall survival in patients who underwent breast cancer surgery performed by one experienced surgeon.

METHODS

All patients who underwent breast cancer surgery by an experienced surgeon between January 2006 and December 2010 were included in this study. Patients were separated into two groups according to the use of desflurane or propofol anesthesia during surgery. Locoregional recurrence and overall survival rates were assessed for the two groups (desflurane or propofol anesthesia). Univariable and multivariable Cox regression models and propensity score matching analyses were used to compare the hazard ratios for death and adjust for potential confounders (age, body mass index, American Society of Anesthesiologists physical status classification, TNM stage, neoadjuvant chemotherapy, Charlson Comorbidity Index, anesthesiologists, and functional status).

RESULTS

Of the 976 breast cancer patients, 632 patients underwent breast cancer surgery with desflurane anesthesia, while 344 received propofol anesthesia. After propensity scoring, 592 patients remained in the desflurane group and 296 patients in the propofol group. The mortality rate was similar in the desflurane (38 deaths, 4%) and propofol (22 deaths, 4%; p = 0.812) groups in 5-year follow-up. The crude hazard ratio (HR) for all patients was 1.13 (95% confidence interval [CI] 0.67-1.92, p = 0.646). No significant difference in the locoregional recurrence or overall 5-year survival rates were found after breast surgery using desflurane or propofol anesthesia (p = 0.454). Propensity score-matched analyses demonstrated similar outcomes in both groups. Patients who received propofol anesthesia had a higher mortality rate than those who received desflurane anesthesia in the matched groups (7% vs 6%, respectively) without significant difference (p = 0.561). In the propensity score-matched analyses, univariable analysis showed an insignificant finding (HR = 1.23, 95% CI 0.72-2.11, p = 0.449). After adjustment for the time since the earliest included patient, the HR remained insignificant (HR = 1.23, 95% CI 0.70-2.16, p = 0.475).

CONCLUSION

In our non-randomized retrospective analysis, neither propofol nor desflurane anesthesia for breast cancer surgery by an experienced surgeon can affect patient prognosis and survival. The influence of propofol anesthesia on breast cancer outcome requires further investigation.

Comparison of the effect of propofol and desflurane on S-100β and GFAP levels during controlled hypotension for functional endoscopic sinus surgery: A randomized controlled trial

BACKGROUND

Although surgical field visualization is important in functional endoscopic sinus surgery (FESS), the complications associated with controlled hypotension for surgery should be considered. Intraoperative hypotension is associated with postoperative stroke, leading to subsequent hypoxia with potential neurologic injury. We investigated the effect of propofol and desflurane anesthesia on S-100β and glial fibrillary acidic protein (GFAP) levels which are early biomarkers for cerebral ischemic change during controlled hypotension for FESS.

METHODS

For controlled hypotension during FESS, anesthesia was maintained with propofol/remifentanil in propofol group (n = 30) and with desflurane/remifentanil in desflurane group (n = 30). For S-100β and GFAP assay, blood samples were taken at base, 20 and 60 minutes after achieving the target range of mean arterial pressure, and at 60 minutes after surgery.

RESULTS

The base levels of S-100β were 98.04 ± 78.57 and 112.61 ± 66.38 pg/mL in the propofol and desflurane groups, respectively. The base levels of GFAP were 0.997 ± 0.486 and 0.898 ± 0.472 ng/mL in the propofol and desflurane groups, respectively. The S-100β and GFAP levels were significantly increased in the study period compared to the base levels in both groups (P ≤ .001). There was no significant difference at each time point between the 2 groups.

CONCLUSION

On comparing the effects of propofol and desflurane anesthesia for controlled hypotension on the levels of S-100β and GFAP, we noted that there was no significant difference in S-100β and GFAP levels between the 2 study groups.

CLINICAL TRIAL REGISTRATION

Available at: http://cris.nih.go.kr, KCT0002698.

Procedural Sedation Outside the Operating Room and Potential Neurotoxicity: Analysis of an At-Risk Pediatric Population

OBJECTIVES

To determine the characteristics of children who met the risk criteria for potential neurotoxicity defined by the US Food and Drug Administration (FDA; 2016 warning) in a procedural sedation (PS) service.

STUDY DESIGN

A single-center retrospective review of all infants and children aged <3 years receiving PS outside the operating room from 2014 to 2016. Demographics, duration of, and the reason for PS were analyzed.

RESULTS

A total of 2950 patients with 3653 sedation encounters were included. Median age was 19 (range, 11-26) months. Most PS (86.4%) were for magnetic resonance imaging (MRI). The median number of sedation procedures per patient was 1 (25th-75th: 1-7), and median duration of sedation was 72 minutes (25th-75th: 55-98 minutes). Forty patients (1.4%) required prolonged sedations >3 hours, in a single encounter (median, [25th-75th] of 196 minutes [185-214 minutes]), and 298 patients (10.1%) had multiple sedation exposures during the study period. Overall, 327 patients, 11.1% (95% confidence interval, 10.0%-12.3%) required repeated and/or prolonged sedation. The most common reasons for repeated or prolonged sedation were MRI of the brain and neurologic concerns.

CONCLUSIONS

Multiple and prolonged PS commonly occurs outside the operating room in this young and potentially vulnerable population. Although certain imaging cannot be avoided, other cases may have the potential to be delayed until the child is >3 years old or to have alternate imaging that may not require prolonged PS. Family and provider awareness of the FDA warnings regarding potential neurotoxicity of sedation in all settings, both inside and outside the operating room, is critical.

Fast Tract Anesthesia Using Isoflurane and Propofol During Off-pump Coronary Artery Bypass Graft Surgery

This study aimed to evaluate myocardial protective effect of isoflurane and propofol as a fast tract anesthesia in off pump coronary artery bypass graft surgery by measuring postoperative cardiac enzyme Troponin-I, and liver enzyme. The study was conducted on 260 patients scheduled to undergo elective off pump coronary artery bypass graft surgery. Patients were randomly allocated to receive either isoflurane or propofol anesthesia and was aimed to extubated within 6 hours. Troponin-I levels were measured preoperatively, at arrival in postoperative intensive care unit, at 12, 24, 48, 72 hours and 4 weeks following surgery. Liver function was also assessed and compared between preoperative and postoperative values. There is no difference in Troponin-I levels between the two studies groups at observed pre and post-operative time intervals. Fast tract anesthesia using isoflurane and propofol provides same myocardial protection during and after OPCABG and overall outcome was excellent.

A meta-analysis of randomized controlled trials: combination of ketamine and propofol versus ketamine alone for procedural sedation and analgesia in children

Although ketamine has been used for procedural sedation and analgesia, some researchers have assessed ketamine-propofol as a better alternative because of its reduced adverse events. The goal of this review was to compare adverse events between ketamine-propofol and ketamine for procedural sedation and analgesia in children. We searched the literature from their inception to May 2018 without the restriction of language. We included all randomized controlled trials comparing ketamine-propofol with ketamine for procedural sedation and analgesia in children. The meta-analysis was conducted using the Stata software. A total of six studies involving 693 individuals were included. Pooling of data showed that subjects with ketamine-propofol had similar incidence of respiratory adverse events compared to those with ketamine (RR 1.16, 95% CI 0.68-1.98). However, ketamine-propofol was effective in reducing cardiovascular adverse events compared to ketamine (RR 0.11, 95% CI 0.04-0.31). Ketamine-propofol was also effective in reducing psychomimetic adverse events compared to ketamine (RR 0.39, 95% CI 0.16-0.93). In regard to nausea and vomiting, ketamine-propofol was significantly effective (RR 0.43, 95% CI 0.25-0.74). In addition, we could not demonstrate differences in efficacious sedation between ketamine-propofol and ketamine. Although our study was not able to demonstrate differences in efficacious sedation between ketamine-propofol and ketamine, we confirmed that ketamine-propofol sedation had a lower frequency of adverse events compared to ketamine sedation in children.

A Comparison of Safety and Efficacy of Dexmedetomidine and Propofol in Children with Autism and Autism Spectrum Disorders Undergoing Magnetic Resonance Imaging

Children with autism and autism spectrum disorders have a high incidence of neurologic comorbidities. Consequently, evaluation with magnetic resonance imaging (MRI) is deemed necessary. Sedating these patients poses several challenges. This retrospective study compared the efficacy and safety of dexmedetomidine to propofol in sedating autistic patients undergoing MRI. There were 56 patients in the dexmedetomidine group and 49 in the propofol group. All of the patients successfully completed the procedure. Recovery and discharge times were significantly lower in the propofol group, while the dexmedetomidine group maintained more stable hemodynamics. Both propofol and dexmedetomidine proved to be adequate and safe medications in the sedation of autistic children undergoing MRI.

Comparing the insertion and ventilation of laryngeal mask airway according to the patient's head position and muscle relaxation use. A prospective clinical trial

OBJECTIVES

To assess the insertion and ventilation of the laryngeal mask airway (LMA) classic while using different head positions with or without muscle relaxant.

METHODS

This is a double-blind randomized clinical trial. Patients scheduled for ureteral calculus surgery at Shanghai General Hospital, Shanghai, China were recruited between November 2017 and November 2018. A total of 132 adults were consecutively selected. Patients were randomly divided into 4 groups according to head positioning and muscle relaxant use. An 8-cm-high pillow was used to achieve the sniffing position. The insertion time, initial peak pressure (Ppeak), mean pressure (Pmean) of the airway during intermittent positive pressure ventilation (primary endpoint) and fiberoptic score of the LMA position (secondary endpoint) were evaluated via electronic bronchoscopy through the mask bar. All adverse events were recorded. Results: Data were analyzed by ANOVA, 2-way ANOVA, Chi-squared, Cochran-Mantel-Haenszel, and Kruskal-Wallis tests. The insertion time required for the first attempt, fiberoptic score, Ppeak and Pmean did not differ among the groups. However, the incidence of adverse events in groups not using muscle relaxant was higher than in those using muscle relaxant. Conclusion: Use of a sniffing position and muscle relaxant slightly eased the insertion of the LMA but did not affect the fiberoptic score or ventilation parameters. Using a muscle relaxant, but not the sniffing position, reduced the incidence of adverse effects.

Propofol-induced refractory status epilepticus at remission age in benign epilepsy with centrotemporal spikes: A case report and literature review

RATIONALE

Benign epilepsy with centrotemporal spikes (BECTS) is one of the most common forms of childhood epilepsy, which is expected to resolve before 16 years of age, with mild effects on the cognitive or behavioral functions in adulthood. This study aims to report the first propofol-induced refractory status epilepticus (SE) in patients with BECTS after 16 years of age, and to review SE in BECTS or induced by propofol.

PATIENT CONCERN

A 16-year-old Chinese girl, who was diagnosed with BECTS at the age of 2 years, developed refractory SE induced by propofol administered during the maintenance stage of general anesthesia during a plastic surgery procedure.

DIAGNOSES

Considering her medical history, EEG, and magnetic resonance images, and brain computed tomography, a diagnosis of refractory SE in BECTS was confirmed.

INTERVENTIONS

The patient had been seizure-free for 3 years from treatment with 2 anti-epileptic drugs (AEDs) valproate acid (VPA) and oxcarbazepine (OXC), and had started monotherapy with OXC for 3 months before the seizure incidence. She had undergone blepharoplasty under local anesthesia prior to receiving general anesthesia. During the maintenance state she developed convulsive SE, which was uncontrolled seizure and lasted for 14 hours. The treatment for which included midazolam, diazepam, propofol, VPA, OXC, and levetiracetam (LEV).

OUTCOMES

The prolonged seizure was controlled by diazepam (4 mg/h), propofol (6 mg/kg/h), VPA (2400 mg/d intravenous injection). Subsequently, she was administered VPA (800 mg/d po), OXC (600 mg/d po), and LEV (1000 mg/d po). Finally, on the 17th day she was discharged, and did not have any seizure recurrence and EEG results were normal as noted during the 3-month follow-up.

LESSONS

This was the first report of an SE in BECTS patient past the remission age. This report implied that interventions of sedation or analgesia in a patient after remission age of BECTS might still be at risk of refractory SE and therefore, should be carefully evaluated and monitored during such procedures, especially when an AED medication has been withdrawn or altered.

Use of Multiple EEG Features and Artificial Neural Network to Monitor the Depth of Anesthesia

The electroencephalogram (EEG) can reflect brain activity and contains abundant information of different anesthetic states of the brain. It has been widely used for monitoring depth of anesthesia (DoA). In this study, we propose a method that combines multiple EEG-based features with artificial neural network (ANN) to assess the DoA. Multiple EEG-based features can express the states of the brain more comprehensively during anesthesia. First, four parameters including permutation entropy, 95% spectral edge frequency, BetaRatio and SynchFastSlow were extracted from the EEG signal. Then, the four parameters were set as the inputs to an ANN which used bispectral index (BIS) as the reference output. 16 patient datasets during propofol anesthesia were used to evaluate this method. The results indicated that the accuracies of detecting each state were 86.4% (awake), 73.6% (light anesthesia), 84.4% (general anesthesia), and 14% (deep anesthesia). The correlation coefficient between BIS and the index of this method was 0.892 (p<0.001). The results showed that the proposed method could well distinguish between awake and other anesthesia states. This method is promising and feasible for a monitoring system to assess the DoA.