Efficacy of sevoflurane as an adjuvant to propofol-based total intravenous anesthesia for attenuating secretions in ocular surgery

[Inhalational anesthetics]

Inhalational anesthetics have been used for induction and maintenance of general anesthesia for more than 150 years. All of the currently used inhalational anesthetics are chlorinated and fluorinated derivatives of ether. Dosing is carried out using the minimal alveolar concentration (MAC) concept. The pharmacokinetic properties of the various inhalational anesthetics are governed by the specific distribution coefficients. Mechanisms of action include specific modulations of various receptors of the central nervous system as well as an unspecific interaction with the cell membrane. Organ toxicity of modern inhalational anesthetics is considered to be minimal. The role of inhalational anesthetics in the context of postoperative nausea and vomiting (PONV) has been reassessed in recent years. The superiority of inhalational anesthetics over intravenous hypnotics with respect to intraoperative awareness is undisputed. The organ protective mechanism of preconditioning is an exclusive property of inhalational anesthetics among all the currently available hypnotics.

Does a combined intravenous-volatile anesthesia offer advantages compared to an intravenous or volatile anesthesia alone: a systematic review and meta-analysis

BACKGROUND

In anesthesia, additive drug interactions are used for reducing dose and dose-dependent side-effects. The combination of propofol with volatile anesthetics is rather unusual but might have advantages compared to the single use regarding PONV, time to extubation, movement during surgery and postoperative pain perception.

METHODS

We searched PubMed, Scopus, Web of Science, and CENTRAL for relevant studies comparing combined intravenous volatile anesthesia with total intravenous or balanced anesthesia. The studies identified were summarized in a meta-analysis with the standardized mean difference or risk ratio as the effect size.

RESULTS

Ten studies provided data. The risk for PONV in the recovery room was significantly reduced for a combined anesthesia compared to a balanced anesthesia (RR 0.657, CI 0.502-0.860, p-value 0.002). There was no significant difference detected either in the time to extubation or in pain perception. Movement during surgery was significantly reduced for a combined compared to a total intravenous anesthesia (RR 0.241, CI 0.135-0.428, p-value 0.000).

CONCLUSIONS

The combination of propofol and volatiles may have some advantages in the early occurrence of PONV compared to a balanced anesthesia. To sufficiently evaluate potential advantages of a combination of volatiles and propofol further high-quality trials are needed.

TRIAL REGISTRATION

PROSPERO CRD42019126627 .

Propofol-based Total Intravenous Anesthesia Is Associated with Better Survival Than Desflurane Anesthesia in Colon Cancer Surgery

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Previous research has shown different effects of anesthetics on cancer cell growth. Here, the authors investigated the association between type of anesthetic and patient survival after elective colon cancer surgery.

METHODS

A retrospective cohort study included patients who received elective colon cancer surgery between January 2005 and December 2014. Patients were grouped according to anesthesia received: propofol or desflurane. After exclusion of those who received combined propofol anesthesia with inhalation anesthesia or epidural anesthesia, survival curves were constructed from the date of surgery to death. After propensity matching, univariable and multivariable Cox regression models were used to compare hazard ratios for death. Subgroup analyses were performed for tumor-node-metastasis staging and postoperative metastasis.

RESULTS

A total of 706 patients (307 deaths, 43.5%) with desflurane anesthesia and 657 (88 deaths, 13.4%) with propofol anesthesia were eligible for analysis. After propensity matching, 579 patients remained in each group (189 deaths, 32.6%, in the desflurane group vs. 87, 15.0%, in the propofol group). In the matched analyses, the propofol-treated group had a better survival, irrespective of lower tumor-node-metastasis stage (hazard ratio, 0.22; 95% CI, 0.11 to 0.42; P < 0.001) or higher tumor-node-metastasis stage (hazard ratio, 0.42; 95% CI, 0.32 to 0.55; P < 0.001) and presence of metastases (hazard ratio, 0.67; 95% CI, 0.51 to 0.86; P = 0.002) or absence of metastases (hazard ratio, 0.08; 95% CI, 0.01 to 0.62; P = 0.016). Simple propensity score adjustment produced similar findings.

CONCLUSIONS

Propofol anesthesia for colon cancer surgery is associated with better survival irrespective of tumor-node-metastasis stage.

Sevoflurane is an effective adjuvant to propofol-based total intravenous anesthesia for attenuating cough reflex in nonintubated video-assisted thoracoscopic surgery

BACKGROUND

Nonintubated video-assisted thoracic surgery (VATS) has been widely developed during the recent years. Cough reflex is an inevitably encountered problem while approaching lung lesions, and it may induce major bleeding. Sevoflurane anesthesia may attenuate cough reflex by inhibiting the pulmonary irritant receptors. However, the incidence of postoperative nausea and vomiting (PONV) in inhalational anesthesia is higher than in the propofol-based total intravenous anesthesia (TIVA). We investigated the effect of sevoflurane combination with propofol-based TIVA on cough reflex and PONV in nonintubated VATS.

METHODS

Ninety patients undergoing nonintubated VATS with laryngeal mask airway (LMA) and spontaneous breathing were randomly assigned for TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 45), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane (P/S) group (n = 45), 1% sevoflurane anesthesia was added to propofol and fentanyl anesthesia. The primary outcome measurements were cough reflex. In addition, the incidence of PONV and extubation time were investigated.

RESULTS

Patients with cough reflex were significantly fewer in the P/S group than in the TIVA group (10/45 vs 34/45; P < .001). The cough severity (35/5/5/0 vs 11/17/17/0; P < .001) and limb movement (40/5/0/0 vs 28/17/0/0; P < .001) were lower in the P/S group than in the TIVA group. Besides, incremental fentanyl bolus for cough reflex was 5 (0 [0-1]) in the P/S group and 17 (0 [0-3]) in the TIVA group (P < .05). And there was no conversion to general anesthesia, postoperative hemorrhage, aspiration pneumonia, or PONV in the 2 groups. Besides, there was no significant difference in extubation time (TIVA: 5.04 ± 2.88 vs P/S: 4.44 ± 2.98 minutes; P = .33).

CONCLUSION

Sevoflurane attenuated cough reflex under propofol-based TIVA and did not increase the incidence of PONV and extubation time in nonintubated VATS.

Learning fiberoptic intubation for awake nasotracheal intubation

Background

Fiberoptic nasotracheal intubation (FNI) is performed if it is difficult to open the mouth or if intubation using laryngoscope is expected to be difficult. However, training is necessary because intubation performed by inexperienced operators leads to complications.

Methods

Every resident performed intubation in 40 patients. Success of FNI was evaluated as the time of FNI. First intubation time was restricted to 2 min 30 s. If the second attempt was unsuccessful, it was considered a failed case, and a specialist performed nasotracheal intubation. If the general method of intubation was expected to be difficult, awake intubation was performed. The degree of nasal bleeding during intubation was also evaluated.

Results

The mean age of the operators (11 men, 7 women) was 27.8 years. FNI was performed in a total of 716 patients. The success rate was 88.3% for the first attempt and 94.6% for the second attempt. The failure rate of intubation in anesthetized patients was 4.9%, and 13.6% in awake patients. When intubation was performed in anesthetized patients, the failure rate from the first to fifth trial was 9.6%, which decreased to 0.7% when the number of trials increased to > 30 times. In terms of awake intubation, there was no failed attempt when the resident had performed the FNI > 30 times. The number of FNIs performed and nasal bleeding were important factors influencing the failure rate.

Conclusion

The success rate of FNI increased as the number of FNI performed by residents increased despite the nasal bleeding.