A comparison of the effect of total intravenous anaesthesia with propofol and remifentanil and inhalational anaesthesia with isoflurane on the release of pro- and anti-inflammatory cytokines in patients undergoing open cholecystectomy

Total intravenous or inhalational volatile anaesthesia and survival after colorectal cancer surgery: a Swedish national registry study

INTRODUCTION

Retrospective studies suggest that inhalational volatile anaesthetic agents may contribute to an increased risk of metastasis and reduction in survival rates when used during cancer surgery. This relationship may vary between cancer types due to different tumour biology and differences in surgical procedures. This study aimed to investigate the relationship between the type of anaesthetic used for maintenance of anaesthesia (propofol or inhalational volatile anaesthetic agent) and survival in patients with stage 1-3 colorectal cancer who underwent resection surgery under general anaesthesia in Sweden between 2014 and 2019.

METHODS

We identified patients from the Swedish Colorectal Cancer Registry. Their data, including cancer characteristics and adjuvant treatment, were then merged with information from the Swedish Peri-operative Registry. The primary outcome was overall survival, with disease-free survival as a secondary outcome.

RESULTS

Of the 11,598 patients included, 8161 had colon cancer and 3437 had rectal cancer. General anaesthesia was maintained with propofol in 2346 (20%) patients, while 9252 (80%) received an inhalational volatile anaesthetic agent. In the unmatched cohort, patients who had general anaesthesia maintained with propofol for colon cancer surgery showed improved survival compared with those receiving an inhalational volatile anaesthetic agent (hazard ratio 0.83, 95%CI 0.72-0.95, p = 0.008). After 1:2 propensity score matching, we observed no significant difference in survival rates in this group (hazard ratio 0.89, 95%CI 0.76-1.04, p = 0.127). In the rectal cancer group, there was no difference in survival in either the unmatched cohort (hazard ratio 0.83, 95%CI 0.65-1.08, p = 0.166) or after propensity score matching (hazard ratio 0.95, 95%CI 0.71-1.25, p = 0.702). There was no significant difference in disease-free survival in either type of cancer.

DISCUSSION

We found no association between the choice of agent for maintenance of anaesthesia and long-term survival outcomes in patients with colorectal cancer.

The Surgical Stress Response and Anesthesia: A Narrative Review

The human physiological response "to stress" includes all metabolic and hormonal changes produced by a traumatic event at the micro or macro cellular levels. The main goal of the body's first response to trauma is to keep physiological homeostasis. The perioperative non-specific adaptation response can sometimes be detrimental and can produce systemic inflammatory response syndrome (SIRS), characterized by hypermetabolism and hyper catabolism. We performed a narrative review consisting of a description of the surgical stress response's categories of changes (neurohormonal and immunological response) followed by reviewing methods found in published studies to modulate the surgical stress response perioperatively. We described various preoperative measures cited in the literature as lowering the burden of surgical trauma. This article revises the anesthetic drugs and techniques that have an impact on the surgical stress response and proven immune-modulatory effects. We also tried to name present knowledge gaps requiring future research. Our review concludes that proper preoperative measures, adequate general anesthetics, multimodal analgesia, early postoperative mobilization, and early enteral nutrition can decrease the stress response to surgery and ease patient recovery. Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system and inflammatory system, with a consecutive impact on cancer recurrence and long-term outcomes.

Comparison between inhalational anesthetics in terms of DNA damage and immunological markers

This study compared genetic damage and immunological markers between surgical patients who underwent inhalational anesthesia with isoflurane or sevoflurane. Blood samples were collected from surgical patients (n = 18 in the isoflurane group and n = 17 in the sevoflurane group) at baseline (before the anesthesia procedure) and the day after anesthesia. DNA damage was detected using an alkaline comet assay; proinflammatory interleukin (IL)-6 was detected by flow cytometry, and white blood cells were detected via an automatic hematology analyzer. The characteristics of both groups were similar, and neither of the two anesthetics induced DNA damage. Similarly, mild neutrophilia was observed after anesthesia in both groups. Increased IL-6 levels were observed 1 day after anesthesia regardless of the type of anesthetic, but this increase was greater in the isoflurane group. Our study suggested that isoflurane and sevoflurane administration may contribute to changes in the immune parameters measured, though no genotoxic hazard was identified, in healthy adult patients who undergo low-stress surgery.

Anti-inflammatory potential of remimazolam: A laboratory and clinical investigation

BACKGROUND

Anesthetic agents, particularly intravenous anesthetics, may affect immune function and tumorigenic factors. We herein investigated whether the anti-inflammatory effects of anesthetic agents are attributed to their antioxidant properties. The antioxidant and anti-inflammatory effects of remimazolam, a new anesthetic, remain unclear. We hypothesized that remimazolam exerts anti-inflammatory effects due to its antioxidant properties, which may affect the postoperative inflammatory response. This retrospective clinical study examined this hypothesis using laboratory and clinical approaches.

METHODS

The antioxidant effects of remimazolam and dexmedetomidine were assessed by electron spin resonance (ESR) spectroscopy, and postoperative inflammatory responses were compared in 143 patients who underwent transcatheter aortic valve replacement at Kindai University Hospital between April 2021 and December 2022. The primary endpoint was the presence or absence of the antioxidant effects of the anesthetics themselves using ESR.

RESULTS

Remimazolam at clinical concentrations exerted antioxidant effects, whereas dexmedetomidine did not. Increases in C-reactive protein (CRP) levels on POD3 from preoperative values were significantly smaller in the remimazolam group than in the dexmedetomidine group (1.33 ± 1.29 vs. 2.17 ± 1.84, p = .014).

CONCLUSIONS

Remimazolam exerted stronger anti-inflammatory effects than dexmedetomidine, and these effects were enhanced by its antioxidant properties, which may have affected postoperative CRP production.

Anesthesia and pain management of pediatric cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has shown to improve survival in patients with extensive or refractory abdominal tumors of many different histologies. Postoperative pain control can be challenging as the surgical procedure is performed through a midline laparotomy incision from xiphoid to symphysis pubis, and patients are usually nothing by mouth for the first 8-10 postoperative days.

AIMS

We present the anesthetic management and postoperative pain control strategies for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy using a multimodal, opioid-sparing, and total intravenous anesthetic technique with a tunneled thoracic epidural.

METHODS

A single institution retrospective review of anesthetic management, intraoperative fluid and blood administration, and postoperative pain control for pediatric patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy between July 2018 and December 2020 was conducted. We employed a novel anesthetic and analgesia protocol consisting of premedication with gabapentin followed by intraoperative infusions of propofol, dexmedetomidine, ketamine, and cisatracurium. A tunneled thoracic epidural catheter was placed for management of pain.

RESULTS

We reviewed and analyzed the first 25 patient records. The most common diagnosis was desmoplastic small round cell tumor (n = 12). Median age of patients was 14 years (range 21 months-22 years). All patients were extubated in the operating room and no patients required reintubation. There were no incidences of acute kidney injury. Epidural infusions were used for a median of 8 days (range 2-14 days). Median postoperative intravenous opioid use (morphine equivalent) through postoperative day 10 was 0.02 mg/kg/day (range 0-0.86 mg/kg/day) administered for a median of 2 days (range 0-17 days). Nine patients (36%) did not require any intravenous opioids in the postoperative period.

CONCLUSIONS

Utilizing a multimodal, opioid-sparing, total intravenous anesthetic technique in conjunction with a tunneled thoracic epidural catheter, we were able to avoid the need for postoperative mechanical ventilation and minimize both intraoperative and postoperative opioid requirements.

Effect of General Anesthesia Maintenance with Propofol or Sevoflurane on Fractional Exhaled Nitric Oxide and Eosinophil Blood Count: A Prospective, Single Blind, Randomized, Clinical Study on Patients Undergoing Thyroidectomy

Background: Nitric oxide (NO) is considered a means of detecting airway hyperresponsiveness, since even non-asthmatic patients experiencing bronchospasm intraoperatively or postoperatively display higher levels of exhaled NO. It can also be used as a non-invasive biomarker of lung inflammation and injury. This prospective, single-blind, randomized study aimed to evaluate the impact of two different anesthesia maintenance techniques on fractional exhaled nitric oxide (FeΝO) in patients without respiratory disease undergoing total thyroidectomy under general anesthesia. Methods: Sixty patients without respiratory disease, atopy or known allergies undergoing total thyroidectomy were randomly allocated to receive either inhalational anesthesia maintenance with sevoflurane at a concentration that maintained Bispectral Index (BIS) values between 40 and 50 intraoperatively or intravenous anesthesia maintenance with propofol 1% targeting the same BIS values. FeΝO was measured immediately preoperatively (baseline), postoperatively in the Postanesthesia Care Unit and at 24 h post-extubation with a portable device. Other variables measured were eosinophil blood count preoperatively and postoperatively and respiratory parameters intraoperatively. Results: Patients in both groups presented lower than baseline values of FeΝO measurements postoperatively, which returned to baseline measurements at 24 h post-extubation. In the peripheral blood, a decrease in the percentage of eosinophils was demonstrated, which was significant only in the propofol group. Respiratory lung mechanics were better maintained in the propofol group as compared to the sevoflurane group. None of the patients suffered intraoperative bronchospasm. Conclusions: Both propofol and sevoflurane lead to the temporary inhibition of NO exhalation. They also seem to attenuate systemic hypersensitivity response by reducing the eosinophil count in the peripheral blood, with propofol displaying a more pronounced effect and ensuring a more favorable mechanical ventilation profile as compared to sevoflurane. The attenuation of NO exhalation by both agents may be one of the underlying mechanisms in the reduction in airway hyperreactivity. The clinical significance of this fluctuation remains to be studied in patients with respiratory disease.

Effects of time on differential leucocyte counts and biochemical parameters of ovariohysterectomy, gastrotomy and intestinal resection and anastomosis in Nigerian indigenous dogs

Differential leucocytes counts and some biochemical parameters could be affected over time by surgical procedures leading to kidney failure. Hence this study evaluates the effects of ovariohysterectomy (OVH), gastrotomy (GAT) and intestinal resection and anastomosis (ITR) on differential leucocyte counts and some biochemical parameters in Nigerian dogs. Twelve dogs of both sexes weighing 10.8±0.7 kg were randomly divided into three experimental groups of four each. The dogs were pre-treated with atropine sulphate (0.04 mg/kg), Xylazine (2 mg/kg) and propofol (6 mg/kg) parenterally, for induction and maintenance of anaesthesia. Pentazocine (3 mg/kg) was injected after surgery. Pre and post-surgery blood samples were obtained at 0, 2, 24, 48, 72, 96, 120 and 144 h respectively to determine differentials in leucocyte counts, electrolytes, lactate, blood urea nitrogen (BUN) and serum creatinine. Mathematical formulas were used to calculate plasma creatinine, creatinine clearance, plasma creatinine clearance, creatinine half- life, urine creatinine and urine volume. There were significant increases (p ≤ 0.05) in mean sodium, chloride and bicarbonate concentrations at 2, 24, 48, 72, 96 and 120 h post-surgery in group 1 and 2, while group 3 had significant decreases (p ≤ 0.05) in sodium, chloride and bicarbonate ions. Lactate value decreased significantly (p<0.05) in group 1, and increased in group 2 and 3 respectively.BUN increased significantly (p<0.05) in group 1,2 and 3.However, there were significant increases (p<0.05) in lymphocyte concentrations in group 1 and 3, respectively. Monocytes decreased significantly (p<0.05) after surgery. Conclusion: Xylazine and propofol anaesthetics cause hyperlactatemia which can be detrimental in surgical patients with co-morbidities.

Association Between Anesthesia Delivered During Tumor Resection and Cancer Survival: a Systematic Review of a Mixed Picture with Constant Themes

BACKGROUND

Surgery is required for cure of most solid tumors, and general anesthesia is required for most cancer surgery. The vast majority of cancer surgery is facilitated by general anesthesia using volatile inhalational agents such as isoflurane and sevoflurane. Only recently have the immunologic and oncologic effect of inhalational agents, and their alternative, propofol-based total intravenous anesthesia (TIVA), come under investigation.

METHODS

Between January 2019 and June 2020, English language articles on PubMed were searched for the keywords "Propofol" "TIVA" or "IV anesthesia" and either "cancer surgery" or "surgical oncology." Duplicates were removes, manuscripts classified as either in vitro, animal, translational, or clinical studies, and their results summarized within these categories.

RESULTS

In-vitro and translational data suggest that inhalational anesthetics are potent immunosuppressive and tumorigenic agents that promote metastasis, while propofol is anti-inflammatory, anti-tumorigenic, and prevents metastasis development. Clinically there is a recurring association, based largely on retrospective, single institution series, that TIVA is associated with significant improvements in disease-free interval and overall survival in a number of, but not all, solid tumors. The longer the surgery is, the more intense the surgical trauma is, the more aggressive the malignancy is, and the higher likelihood of an association is.

DISCUSSION

Prospective randomized trials, coupled with basic science and translational studies, are needed to further define this association.

The influence of propofol-based total intravenous anesthesia on postoperative outcomes in end-stage renal disease patients: A retrospective observation study

Background

To determine whether the anesthetic method of propofol total intravenous anesthesia (TIVA) is associated with postoperative outcome in ESRD patients, we evaluated the incidence of postoperative major adverse cardiac events (MACE), comparing propofol TIVA versus anesthesia with volatile anesthesia in ESRD patients.

Methods

Retrospectively, we identified cases with ESRD patients who underwent surgery under general anesthesia. Patients were divided into those who received only volatile anesthesia (volatile group) and those who received only propofol TIVA (TIVA group). The incidence of MACE and potential confounding variables were compared separately in a univariate logistic model and subsequently by multivariate logistic regression.

Results

Among the 2576 cases in ESRD patients, 1374 were in the TIVA group and 1202 were in the volatile group. The multivariate analysis included 12 factors, including the anesthesia method, of which five factors were significant. Factors that were associated with a significantly lower MACE risk included preoperative chloride concentration (OR: 0.96; 95% CI, 0.92–0.99), baseline SBP (OR: 0.98; 95% CI, 0.98–0.99), and propofol TIVA (OR: 0.37; 95% CI, 0.22–0.60).

Conclusions

We inferred that the anesthetic method associated with the postoperative outcome in patients with ESRD.

Is It Definitely Clear That Long-Term Survival after Breast Cancer Surgery Is Not Affected by Anaesthetics?

Retrospective studies indicate that cancer survival may be affected by the anaesthetic technique. Propofol seems to be a better choice than volatile anaesthetics, such as sevoflurane. The first two retrospective studies suggested better long-term survival with propofol, but not for breast cancer. Subsequent retrospective studies from Asia indicated the same. When data from seven Swedish hospitals were analysed, including 6305 breast cancer patients, different analyses gave different results, from a non-significant difference in survival to a remarkably large difference in favour of propofol, an illustration of the innate weakness in the retrospective design. The largest randomised clinical trial, registered on clinicaltrial.gov, with survival as an outcome is the Cancer and Anesthesia study. Patients are here randomised to propofol or sevoflurane. The inclusion of patients with breast cancer was completed in autumn 2017. Delayed by the pandemic, one-year survival data for the cohort were presented in November 2020. Due to the extremely good short-term survival for breast cancer, one-year survival is of less interest for this disease. As the inclusions took almost five years, there was also a trend to observe. Unsurprisingly, no difference was found in one-year survival between the two groups, and the trend indicated no difference either.

Prognostic significance of propofol-based intravenous anesthesia in early-stage lung cancer surgery

PURPOSE

The purpose of this study was to assess whether the anesthetic type is associated with the prognosis of pathological stage I non-small cell lung cancer (NSCLC).

METHODS

Clinicopathological data from 431 consecutive patients who underwent lobectomy for NSCLC between 2010 and 2016 were collected. Patients were classified into groups according to the type of anesthesia: propofol-based total intravenous anesthesia (TIVA) or inhalation anesthesia (INHA). We investigated the prognostic differences between these two groups.

RESULTS

A total of 72 patients in the TIVA group and 158 patients in the INHA group were eligible for the analysis. Recurrence was observed in 4 (5.6%) patients in the TIVA group and 19 (12.0%) patients in the INHA group (P = 0.159), and all-cause death occurred in 4 (5.6%) patients in the TIVA group and 24 (15.2%) patients in the INHA group (P = 0.049). The 5-year recurrence-free survival (RFS) and overall survival rates of the TIVA/INHA groups were 91.7%/77.4% and 94.4%/83.5%, respectively. TIVA was associated with a significantly better prognosis. A multivariable analysis of factors associated with RFS revealed that the type of anesthesia as a significant prognostic factor (P = 0.047).

CONCLUSION

Propofol-based TIVA was associated with a better prognosis in comparison to INHA in patients with surgically resected pathological stage I NSCLC.

Comparison of the effects of intravenous propofol and inhalational desflurane on the quality of early recovery after hand-assisted laparoscopic donor nephrectomy: a prospective, randomised controlled trial

OBJECTIVES

We compared early recovery outcomes between living kidney donors who received total intravenous (IV) propofol versus inhalational desflurane during hand-assisted laparoscopic nephrectomy.

DESIGN

A single-centre, prospective randomised controlled trial.

SETTING

University hospital.

PARTICIPANTS

Study participants were enrolled between October 2019 and February 2020. A total of 80 living donors were randomly assigned to an intravenous propofol group (n=40) or a desflurane group (n=40).

INTERVENTION

Propofol group received intravenous propofol and desflurane group received desflurane, as a maintenance anaesthetic.

PRIMARY AND SECONDARY OUTCOME MEASURES

The quality of postoperative functional recovery was primarily assessed using the Korean version of the Quality of Recovery-40 (QoR-40K) questionnaire on postoperative day 1. Secondarily, ambulation, pain score, rescue analgesics, complications and total hospital stay were assessed postoperatively.

RESULTS

Our study population included 35 males and 45 females. The mean age was 46±13 years. The global QoR-40K score (161 (154-173) vs 152 (136-161) points, respectively, p=0.001) and all five subdimension scores (physical comfort, 49 (45-53) vs 45 (42-48) points, respectively, p=0.003; emotional state, 39 (37-41) vs 37 (33-41) points, respectively, p=0.005; psychological support, 30 (26-34) vs 28 (26-32) points, respectively, p=0.04; physical independence, 16 (11-18) vs 12 (8-14) points, respectively, p=0.004; and pain, 31 (28-33) vs 29 (25-31) points, respectively, p=0.021) were significantly higher in the intravenous propofol group than the desflurane group. The early ambulation success rate and numbers of early and total steps were higher, but the incidence of nausea/vomiting was lower, in the intravenous propofol group than the desflurane group. The total hospital stay after surgery was shorter in the intravenous propofol group than the desflurane group.

CONCLUSIONS

Intravenous propofol may enhance the quality of postoperative recovery in comparison to desflurane in living kidney donors.

TRIAL REGISTRATION NUMBER

KCT0004365.

Comparison of the Effects of Low-flow and Normal-flow Desflurane Anaesthesia on Inflammatory Parameters in Patients Undergoing Laparoscopic Cholecystectomy

Objective

According to previous studies, anaesthesia type has an important effect on immune response. However, there are limited data determining the effect of low-flow and normal-flow desflurane anaesthesia on inflammatory parameters. This study aimed to investigate the effect of low-flow and normal-flow desflurane anaesthesia on inflammatory parameters in patients undergoing laparoscopic cholecystectomy.

Methods

A total of 92 patients who underwent laparoscopic cholecystectomy were retrospectively included in this study. The patients were divided into the following 2 groups according to the type of anaesthesia they received: low-flow desflurane anaesthesia group (fresh gas flow rate: 0.5 L min^-1) and normal-flow desflurane anaesthesia group (fresh gas flow rate: 2 L min^-1). Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were obtained before the procedure and 6 hours after the end of the procedure for all patients.

Results

Although pre-procedural NLR and PLR were similar between the normal-flow and low-flow anaesthesia groups, post-procedural NLR (4.38±2.00 vs. 3.51±1.37, p=0.023) and PLR (144.38±71.04 vs. 120.58±35.35, p=0.037) were significantly higher in the normal-flow anaesthesia group. In addition, compared with pre-procedural values, post-procedural NLR (from 2.31±1.02 to 4.38±2.00, p<0.001) and PLR (from 125.60±50.97 to 144.38±71.04, p=0.017) were significantly increased in the normal-flow anaesthesia group, whereas post-procedural NLR (from 2.88±2.51 to 3.51±1.37, p=0.135) and PLR (from 121.86±42.78 to 120.58±35.35, p=0.847) did not change significantly in the low-flow anaesthesia group.

Conclusion

The study results indicated that postoperative inflammatory response was significantly lower with low-flow desflurane anaesthesia than with normal-flow desflurane anaesthesia.

Comparison of the impact of propofol versus sevoflurane on early postoperative recovery in living donors after laparoscopic donor nephrectomy: a prospective randomized controlled study

Background

Enhancing postoperative recovery of the donor is important to encourage living kidney donation. We investigated the effects of anesthetic agents (intravenous [IV] propofol versus inhaled [IH] sevoflurane) on the quality of early recovery of healthy living kidney donors after hand-assisted laparoscopic nephrectomy (HALN) under analgesic intrathecal morphine injection.

Methods

This single-center, prospective randomized controlled study enrolled 80 living donors undergoing HALN from October 2019 to June 2020 at Seoul St. Mary’s Hospital. Donors were randomly assigned to the IV propofol group or IH sevoflurane group. To measure the quality of recovery, we used the Korean version of the Quality of Recovery-40 questionnaire (QoR-40 K) on postoperative day (POD) 1, and ambulation (success rate, number of footsteps) 6–12 h after surgery and on POD 1. The pain score for the wound site, IV opioid requirement, postoperative complications including incidences of nausea/vomiting, and length of in-hospital stay were also assessed.

Results

The global QoR-40 K score and all subscale scores (physical comfort, emotional state, physical independence, psychological support, and pain) were significantly higher in the IV propofol group than in the IH sevoflurane group. The numbers of footsteps at all time points were also higher in the IV propofol group. Donors in the IV propofol group had a lower incidence of nausea/vomiting, and a shorter hospitalization period.

Conclusions

Total IV anesthesia with propofol led to better early postoperative recovery than that associated with IH sevoflurane.

Trial registration

Clinical Research Information Service, Republic of Korea (approval number: KCT0004351) on October 18, 2019.

Survival after primary breast cancer surgery following propofol or sevoflurane general anesthesia-A retrospective, multicenter, database analysis of 6305 Swedish patients

BACKGROUND

Retrospective studies indicate that the choice of anesthetic can affect long-term cancer survival. Propofol seems to have an advantage over sevoflurane. However, this is questioned for breast cancer. We gathered a large cohort of breast cancer surgery patients from seven Swedish hospitals and hypothesized that general anesthesia with propofol would be superior to sevoflurane anesthesia regarding long-term breast cancer survival.

METHODS

We identified all patients who were anaesthetized for breast cancer surgery between 2006 and 2012. The patients were matched to the Swedish Breast Cancer Quality Register, to retrieve tumor characteristics, prognostic factors, and adjuvant treatment as well as date of death. Overall survival between patients undergoing sevoflurane and propofol anesthesia was analyzed with different statistical approaches: (a) multiple Cox regression models adjusted for demographic, oncological, and multiple control variables, (b) propensity score matching on the same variables, but also including the participating centers as a cofactor in a separate analysis.

RESULTS

The database analysis identified 6305 patients. The 5-year survival rates were 91.0% and 81.8% for the propofol and sevoflurane group, respectively, in the final model (P = .126). Depending on the statistical adjustment method used, different results were obtained, from a non-significant to a "proposed" and even a "determined" difference in survival that favored propofol, with a maximum of 9.2 percentage points higher survival rate at 5 years (hazard ratio 1.46, 95% CI 1.10-1.95).

CONCLUSIONS

It seems that propofol may have a survival advantage compared with sevoflurane among breast cancer patients, but the inherent weaknesses of retrospective analyses were made apparent.

Total intravenous anaesthesia with tumescent infiltration anaesthesia without definitive airway for early excision and skin grafting in a major burn - A prospective observational study

Background and Aims:

Patients with major burns posted for early tangential excision and skin grafting pose peculiar challenges for anaesthesiologists. The purpose of the study was to assess safety and efficacy of total intravenous anaesthesia (TIVA) with tumescent infiltration anaesthesia (TIA) for these burn procedures.

Methods:

This observational single-arm study was conducted on 48 cases of a tertiary centre burn unit, requiring early tangential excision and skin grafting between third and fifth days of burn injury. TIVA was administered using a combination of intravenous (iv) infusion of injection dexmedetomidine and iv boluses of fentanyl, ketamine, propofol, midazolam and paracetamol. TIA was administered in burn wounds after aseptic preparation. Spontaneous breathing was maintained with oxygen supplementation. Haemodynamic and respiratory monitoring was done intraoperatively every 15 minutes and for 6 hours postoperatively. Modified Aldrete's score was calculated at 10 minutes after completion of surgery. Statistical analysis was done using statistical package for the social science software (version 16). Descriptive statistics were used for quantitative variables.

Results:

Baseline mean HR was 106.95 ± 11.17 bpm (beats per minute). HR settled at 73.17 ± 6.97 bpm during the intraoperative period. The baseline mean arterial pressure (MAP) of 82.42 ± 10.04 mmHg was maintained at 81 ± 7.32 mmHg during the intraoperative period. In all, 95.8% achieved early recovery with mean modified Aldrete's score of ≥9 at 10 minutes post-surgery. There was no episode of apnoea or desaturation.

Conclusion:

TIVA in combination with TIA minimally interferes with homeostasis and promotes early recovery in patients undergoing early excision and grafting in major burns.

Influence of propofol-based total intravenous anaesthesia on peri-operative outcome measures: a narrative review

Propofol-based total intravenous anaesthesia is well known for its smooth, clear-headed recovery and anti-emetic properties, but there are also many lesser known beneficial properties that can potentially influence surgical outcome. We will discuss the anti-oxidant, anti-inflammatory and immunomodulatory effects of propofol and their roles in pain, organ protection and immunity. We will also discuss the use of propofol in cancer surgery, neurosurgery and older patients.

The effect of anesthesia on the postoperative systemic inflammatory response in patients undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Surgical injury stimulates the systemic inflammatory response. The magnitude of the postoperative systemic inflammatory response has been shown to be significantly associated with short and long-term outcomes following surgery of varying severity. Different anesthetic techniques for surgery may have an impact on the postoperative systemic inflammatory response and on the rate of the postoperative infective complications.The aim of the present systematic review was to examine the relationship between perioperative anesthesia, the postoperative systemic inflammatory response and postoperative infective complications in patients undergoing surgery.

METHODS

This was carried out using PubMed and other established databases from 1987 up to March 2018. In particular, randomized controlled studies and systemic inflammation markers, interleukin 6 and C-reactive protein were examined.

RESULTS

Overall, 60 controlled, randomized clinical trials were included in the review. The mean or median values of both interleukin 6 and C-reactive protein were taken for each study and the mean value was calculated for each anesthetic group at sampling points of 12-24 and 24-72 hours for interleukin 6 and C-reactive protein respectively. When taking the magnitude of surgery into account, TIVA using propofol was significantly associated with a reduction in particular C-reactive protein (P = .04). However, there were no other specific anesthetic methods including general, regional and combined anesthetics that were associated with a reduction in either interleukin 6 or C-reactive protein.

CONCLUSION

There is some evidence that anesthetic regimens may reduce the magnitude of the postoperative systemic inflammatory response. However, the studies were heterogeneous and generally of low quality.Future, well conducted, adequately powered studies are required to clarify the effect of anesthesia on the postoperative systemic inflammatory response and infective complications.

Comparison of Biochemical Recurrence After Robot-assisted Laparoscopic Radical Prostatectomy with Volatile and Total Intravenous Anesthesia

Aims: Recurrence after cancer surgery is a major concern in patients with cancer. Growing evidence from preclinical studies has revealed that various anesthetics can influence the immune system in different ways. The current study compared the long-term biochemical recurrence of prostate cancer after robot-assisted laparoscopic radical prostatectomy (RALP) in terms of selection of anesthetic agent between total intravenous anesthesia (TIVA) with propofol/remifentanil and volatile anesthetics (VA) with sevoflurane or desflurane/remifentanil. Methods: We followed up oncologic outcomes of patients who underwent RALP from two previous prospective randomized controlled trials, and the outcomes of those who received TIVA (n = 64) were compared with those who received VA (n = 64). The follow-up period lasted from November 2010 to March 2019. Results: Both TIVA and VA groups showed identical biochemical recurrence-free survivals at all-time points after RALP. The following predictive factors of prostate cancer recurrence were determined by Cox regression: colloid input [hazard ratio (HR)=1.002, 95% confidence interval (CI): 1.000-1.003; P = 0.011], initial prostate-specific antigen level (HR=1.025, 95% CI: 1.007-1.044; P = 0.006), and pathological tumor stage 3b (HR=4.217, 95% CI:1.207-14.735; P = 0.024), but not the anesthetic agent. Conclusions: Our findings demonstrate that both TIVA with propofol/remifentanil and VA with sevoflurane or desflurane/remifentanil have comparable effects on oncologic outcomes in patients undergoing RALP.

Anesthetics and long-term survival after cancer surgery-total intravenous versus volatile anesthesia: a retrospective study

Background

Intravenous anesthesia has been reported to have a favorable effect on the prognosis of cancer patients. This study was performed to analyze data regarding the relation between anesthetics and the prognosis of cancer patients in our hospital.

Methods

The medical records of patients who underwent surgical resection for gastric, lung, liver, colon, and breast cancer between January 2006 and December 2009 were reviewed. Depending on the type of anesthetic, it was divided into total intravenous anesthesia (TIVA) or volatile inhaled anesthesia (VIA) group. The 5-year overall survival outcomes were analyzed by log-rank test. Cox proportional hazards modeling was used for sensitivity.

Results

The number of patients finally included in the comparison after propensity matching came to 729 in each group. The number of surviving patients at 5 years came to 660 (90.5%) in the TIVA and 673 (92.3%) in the VIA. The type of anesthetic did not affect the 5-year survival rate according to the log-rank test (P = 0.21). Variables associated with a significant increase in the hazard of death after multivariable analysis were male sex and metastasis at surgery.

Conclusions

There were no differences in 5-year overall survival between two groups in the cancer surgery.

Trial registration

Trial registration: CRIS KCT0004101. Retrospectively registered 28 June 2019.

Rationale and Design of the CAN Study: an RCT of Survival after Propofol- or Sevoflurane-based Anesthesia for Cancer Surgery

Background:

Based on animal data only, some clinicians have adopted propofol-based anesthesia for cancer surgery with the aim of increased survival.

Objective:

Our objective is to verify or refute the hypothesis that survival increases after cancer surgery with propofol compared with sevoflurane for anesthesia maintenance. This aim deserves a large-scale randomized study. The primary hypothesis is an absolute increase of minimum 5%-units in 1- and 5-year survival with propofol- based anesthesia for breast or colorectal cancer after radical surgery, compared with sevoflurane-based anesthesia.

Method:

Ethics and medical agency approvals were received and pre-study registrations at clinicaltrial.gov and EudraCT were made for our now ongoing prospective, randomized, open-label, multicenter study. A power analysis based on a retrospective study, including a safety margin for drop outs, resulted in a total requirement of 8,000 patients. The initial inclusion period constituted a feasibility phase with an emphasis on the functionality of the infrastructure at the contributing centers and at the monitoring organization, as well as on protocol adherence.

Conclusion:

The infrastructure and organization work smoothly at the different contributing centers. Protocol adherence is good, and the monitors are satisfied. We expect this trial to be able to either verify or refute that propofol is better than sevoflurane for cancer surgery.

Effect of Equipotent Doses of Propofol versus Sevoflurane Anesthesia on Regulatory T Cells after Breast Cancer Surgery

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Clusters of differentiation 39 and 73, enzymes expressed on the surface of regulatory T cells, promote cancer recurrence and metastasis by suppressing immune cells. The authors hypothesized that propofol is less immunosuppressive than volatile anesthetics. The objective of this randomized trial was to compare the changes in cluster of differentiation 39 and 73 expression on regulatory T cells between propofol- and sevoflurane-based anesthesia during breast cancer surgery.

METHODS

A total of 201 patients having breast cancer surgery were randomly assigned and analyzed (n = 99 for propofol, n = 102 for sevoflurane). Blood samples were obtained immediately before anesthesia induction and 1 and 24 h postoperatively. The frequency of cluster of differentiation 39 and 73 expression on circulating regulatory T cells (primary outcome) and the frequency of circulating type 1 and type 17 helper T cells, natural killer cells, and cytotoxic T cells were investigated. Serum cytokines and the neutrophil-to-lymphocyte ratio were also evaluated.

RESULTS

Changes in cluster of differentiation 39 and 73 expression on regulatory T cells over time did not differ with propofol and sevoflurane groups (difference [95% confidence interval]: 0.01 [-2.04 to 2.06], P = 0.995 for cluster of differentiation 39; -0.93 [-3.12 to 1.26], P = 0.403 for cluster of differentiation 73). There were no intergroup differences in type 1, type 17 helper T cells, natural killer cells, cytotoxic T cells, cytokines, or the neutrophil-to-lymphocyte ratio.

CONCLUSIONS

Changes in immune cells were similar with propofol and sevoflurane during breast cancer surgery. The effect of anesthetics on the perioperative immune activity may be minimal during cancer surgery.

Effect of Perioperative Lidocaine, Propofol and Steroids on Pulmonary Metastasis in a Murine Model of Breast Cancer Surgery

Addressing the hypothesis that anaesthetic-analgesic technique during cancer surgery might influence recurrence or metastatic spread is a research priority. Propofol, which has anti-inflammatory properties in vitro, is clinically associated with reduced risk of cancer recurrence compared with sevoflurane anaesthesia in retrospective studies. Amide local anaesthetics, such as lidocaine, have cancer inhibiting effects in vitro. Steroids have anti-inflammatory and immunosuppressive effects and are associated with improved recovery after major non-cancer surgery. We compared the effects of propofol, lidocaine and methylprednisolone on postoperative metastasis in a murine model of breast cancer surgery under sevoflurane anaesthesia. 4T1 tumour cells were introduced into the mammary fat-pad of female BALB/c mice and the resulting tumour resected seven days later under general anaesthesia with sevoflurane. Mice (n = 72) were randomized to four treatment groups: Sevoflurane alone (control); Propofol group received 5 mg.kg-1; Lidocaine group received 1.5 mg.kg-1 followed by 2 mg.kg-1.h-1 infusion; Methylprednisolone group received 30 mg.kg-1 methylprednisolone. The primary outcome measure was pulmonary metastasis colony count, as assessed by in-vitro proliferation, two weeks post-operatively. This was achieved by treating the post-mortem lung tissue with collagenase IV, straining and culturing for 14 days prior to colony count. Compared with control, lidocaine and propofol each individually reduced pulmonary metastasis colonies; mean (SD) 846 (±581) vs. 88 (±52) vs. 34 (±44) respectively, (p = 0.0001 and p = 0.0001). Methylprednisolone increased lung metastasis, 2555 (±609) vs. 846 (±581), p = 0.0001. Post-operative hepatic metastatic disease and serum interleukin-6 and vascular endothelial growth factor levels were similar in all groups. In conclusion, in a murine model of breast cancer surgery during sevoflurane anaesthesia, propofol and lidocaine each decreased pulmonary metastasis, while methylprednisolone increased it.

Perioperative C-reactive protein is associated with pain outcomes after major laparoscopic abdominal surgery: a retrospective analysis

Purpose: This study is aimed to investigate an association between perioperative C-reactive protein (CRP) levels and both opioid consumption and postoperative pain scores in postoperative days (PODs) in patients who underwent laparoscopic major abdominal surgery. We hypothesized that postoperative opioid requirements and numeric rating scale (NRS) pain scores would be positively associated with perioperative CRP levels.

Patients and method: Medical records from 4,653 patients who underwent a laparoscopic major abdominal surgery from January 2010 to December 2016 were retrospectively reviewed. Generalized linear regression analysis was used to identify the association of preoperative and postoperative CRP levels, and increase in CRP level (postoperative CRP level – preoperative CRP level) with postoperative pain outcomes during POD 0–3.

Results: An increase of 1 mg dL⁻¹ of postoperative CRP level was significantly associated with 1.4% increase morphine equivalent consumption [exponentiated regression (Exp) coefficient: 0.014, 95% CI (0.011, 0.016), P<0.001], whereas preoperative CRP levels were not significantly associated with morphine equivalent consumption on POD 0–3 (P=0.450). A 1 mg dL⁻¹ of increase in CRP level was significantly associated with 1% increase of morphine equivalent consumption [Exp coefficient: 0.010, 95% CI (0.008, 0.012), P<0.001]. Postoperative CRP levels were positively associated with NRS pain scores on POD 1, POD 2, and POD 3 (P<0.001). Increases of CRP levels were also positively associated with NRS pain scores on POD 0, POD 1, POD2, and POD3 (P<0.05).

Conclusion: These results suggest postoperative CRP levels and increases in CRP levels are positively associated with opioid consumption and higher pain scores after major laparoscopic abdominal surgery.

Total Intravenous Anesthesia versus Inhalation Anesthesia for Breast Cancer Surgery

EDITOR’S PERSPECTIVE

What We Know about This Topic

IV anesthesia may impair anticancer immunity less than volatile anesthesia and therefore reduce recurrence risk

What This Article Tells Us That Is New

In a large propensity-matched retrospective cohort analysis, the authors compared total IV and volatile anesthesia for breast cancer surgery

Recurrence hazard was similar with each approach

Selection of IV or volatile anesthesia should be based on factors other than cancer recurrence

Background

The association between type of anesthesia used and recurrence of cancer remains controversial. This retrospective cohort study compared the influence of total IV anesthesia and inhalation anesthesia on the primary outcome of recurrence-free survival after breast cancer surgery.

Methods

The authors reviewed the electronic medical records of patients who had breast cancer surgery at a tertiary care teaching hospital between January 2005 and December 2013. The patients were grouped according to whether IV or inhalation anesthesia was used for surgery. Propensity score matching was used to account for differences in baseline characteristics. Kaplan–Meier survival curves were constructed to evaluate the influence of type of anesthesia on recurrence-free survival and overall survival. The risks of cancer recurrence and all-cause mortality were compared between each type of anesthesia.

Results

Of 7,678 patients who had breast cancer surgery during the study period, data for 5,331 patients were available for analysis (IV group, n = 3,085; inhalation group, n = 2,246). After propensity score matching, 1,766 patients remained in each group. Kaplan–Meier survival curves showed that there was no significant difference in recurrence-free survival or overall survival between the two groups, with 5-yr recurrence-free survival rates of 93.2% (95% CI, 91.9 to 94.5) in the IV group and 93.8% (95% CI, 92.6 to 95.1) in the inhalation group. Inhalation anesthesia had no significant impact on recurrence-free survival (hazard ratio, 0.96; 95% CI, 0.69 to 1.32; P = 0.782) or overall survival (hazard ratio, 0.96; 95% CI, 0.69 to 1.33, P = 0.805) when compared with total IV anesthesia.

Conclusions

The authors found no association between type of anesthesia used and the long-term prognosis of breast cancer. The results of this retrospective cohort study do not suggest specific selection of IV or inhalation anesthesia for breast cancer surgery.

Effects of propofol/remifentanil-based total intravenous anesthesia versus sevoflurane-based inhalational anesthesia on the release of VEGF-C and TGF-β and prognosis after breast cancer surgery: a prospective, randomized and controlled study

Background

Vascular endothelial growth factor (VEGF) and transforming growth factor-β (TGF-β) have been involved in tumor growth and metastasis. Sevoflurane may promote angiogenesis, whereas propofol can present an anti-angiogenic effect. In this study, we compared the effects of propofol/remifentanil-based total intravenous anesthesia (TIVA) and sevoflurane-based inhalational anesthesia on the release of VEGF-C and TGF-β, as well as recurrence- free survival (RFS) rates in the patients undergoing breast cancer surgery.

Methods

Eighty female patients undergoing breast cancer resection were enrolled and randomized to receive either sevoflurane-based inhalational anesthesia (SEV group) or propofol/remifentanil-based TIVA (TIVA group). The serum concentrations of VEGF-C and TGF-β before and 24 h after surgery were measured and RFS rates over a two-year follow-up were analyzed in both groups. The postoperative pain scores assessed using a visual analogue scale (VAS) and the use of perioperative opioids were also evaluated.

Results

Although VAS scores at 2 h and 24 h after surgery were comparable between the two groups, there were more patients receiving postoperative fentanyl in the TIVA group (16[40%]) compared with the SEV group (6[15%], p = 0.023). VEGF-C serum concentrations increased after surgery from 105 (87–193) pg/ml to174 (111–281) pg/ml in the SEV group (P = 0.009), but remained almost unchanged in the TIVA group with 134 (80–205) pg/ml vs.140(92–250) pg/ml(P = 0.402). The preoperative to postoperative change for VEGF-C of the SEV group (50 pg/ml) was significantly higher than that of the TIVA group (12 pg/ml) with a difference of 46 (− 11–113) pg/ml (P = 0.008). There were also no significant differences in the preoperative and postoperative TGF-β concentrations between the two groups. The two-year RFS rates were 78% and 95% in the SEV and TIVA groups (P = 0.221), respectively.

Conclusion

In comparison with sevoflurane-based inhalational anesthesia, propofol/remifentanil -based total intravenous anesthesia can effectively inhibit the release of VEGF-C induced by breast surgery, but didn’t seem to be beneficial in the short-term recurrence rate of breast cancer.

Trial registration

Chictr.org.cn ChiCTR1800017910. Retrospectively Registered (Date of registration: August 20, 2018).

Remifentanil suppresses increase in interleukin-6 mRNA in the brain by inhibiting cyclic AMP synthesis

PURPOSE

Neuronal inflammation is caused by systemic inflammation and induces cognitive dysfunction. IL-6 plays a crucial role in therapies for neuronal inflammation and cognitive dysfunction. Remifentanil, an ultra-short-acting opioid, controls inflammatory reactions in the periphery, but not in the brain. Therefore, the anti-inflammatory effects of remifentanil in neuronal tissue and the involvement of cAMP in these effects were investigated in the present study.

METHODS

Mice were divided into 4 groups: control, remifentanil, LPS, and LPS + remifentanil. Brain levels of pro-inflammatory cytokine mRNA, and serum levels of corticosterone, catecholamine and IL-6 were measured in the 4 groups. The co-localization of IL-6 and astrocytes in the mouse brain after the LPS injection was validated by immunostaining. LPS and/or remifentanil-induced changes in intracellular cAMP levels in cultured glial cells were measured, and the effects of cAMP on LPS-induced IL-6 mRNA expression levels were evaluated.

RESULTS

Remifentanil suppressed increase in IL-6 mRNA levels in the mouse brain, and also inhibited the responses of plasma IL-6, corticosterone, and noradrenaline in an inflammatory state. In the hypothalamus, IL-6 was localized in the median eminence, at which GFAP immunoreactivity was specifically detected. In cultured cells, remifentanil suppressed increase in IL-6 mRNA levels and intracellular cAMP levels after the administration of LPS, and this enhanced IL-6 mRNA expression in response to LPS.

CONCLUSION

Remifentanil suppressed increase in IL-6 mRNA levels in the brain in an inflammatory state, and this effect may be attributed to its direct action on neuronal cells through the inhibition of intracellular cAMP rather than corticosterone.

The synergistic effect of propofol and ulinastatin suppressed the viability of the human lung adenocarcinoma epithelial A549 cell line

Ulinastatin and propofol (PPF) are recognized for their anticancer properties. The aim of the present study was to evaluate the synergistic antitumor effect of PPF followed by ulinastatin against A549 cells. In MTT assays, PPF (10, 20 and 30 µM) followed by 200 U/ml ulinastatin was more effective at inhibiting A549 cell viability compared with PPF (10, 20 and 30 µM) or 200 U/ml ulinastatin. PPF (10, 20 and 30 µM) followed by 200 U/ml ulinastatin treatments synergistically increased the number of S cells and synergistically reduced the number of G2/M cells associated with PPF stimulation in a dose-dependent manner. Western blot analysis demonstrated that the antitumor effect of PPF followed by 200 U/ml ulinastatin treatments were associated with the downregulated expression of extracellular signal-regulated kinase 1 and 2 phosphorylation (p-ERK1/2) and matrix metalloproteinases 2 (MMP-2). In conclusion, these data demonstrated that PPF (20 and 30 µM) followed by 200 U/ml ulinastatin treatments synergistically stimulated a significant proportion of A549 cells in S phase. Furthermore, the combination synergistically reduced a significant proportion of A549 cells in G2/M phase and synergistically suppressed the viability of A549 cells, which was possibly related regulation of the expression of p-ERK1/2 and MMP-2 in A549 cells.

Inhalational Anesthetics Induce Neuronal Protein Aggregation and Affect ER Trafficking

Anesthetic agents have been implicated in the causation of neurological and cognitive deficits after surgery, the exacerbation of chronic neurodegenerative disease, and were recently reported to promote the onset of the neurologic respiratory disease Congenital Central Hypoventilation Syndrome (CCHS), related to misfolding of the transcription factor Phox2B. To study how anesthetic agents could affect neuronal function through alterations to protein folding, we created neuronal cell models emulating the graded disease severity of CCHS. We found that the gas anesthetic isoflurane and the opiate morphine potentiated aggregation and mislocalization of Phox2B variants, similar to that seen in CCHS, and observed transcript and protein level changes consistent with activation of the endoplasmic reticulum (ER) unfolded protein response. Attenuation of ER stress pathways did not result in a correction of Phox2B misfolding, indicating a primary effect of isoflurane on protein structure. We also observed that isoflurane hindered the folding and activity of proteins that rely heavily on ER function, like the CFTR channel. Our results show how anesthetic drugs can alter protein folding and induce ER stress, indicating a mechanism by which these agents may affect neuronal function after surgery.

Golgi fragmentation induced by overactivated cyclin-dependent kinase 5 is associated with isoflurane-induced neurotoxicity

Overactivated cyclin-dependent kinase 5 (Cdk5) induces Golgi fragmentation, which interrupts the processing and trafficking of secretory cargo and subsequently synaptic plasticity and synaptogenesis, and even leads to neuronal cell death. Cdk5 overactivation and subsequent Golgi fragmentation are involved in many neurodegenerative diseases. However, whether isoflurane-induced neurotoxicity is relevant to aberrant Cdk5 activation and subsequent Golgi fragmentation remains unknown. In the present study, we explored the underlying molecular mechanisms of isoflurane-induced neurotoxicity in primary cultured hippocampal neurons. After treatment with 2% isoflurane for 6 h, immunofluorescence staining and transmission electron microscopy were used to examine the Golgi structure. Neuronal viability was evaluated using the 3-(4,5-dimethyithiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT) assay and TUNEL staining. Cdk5 activity was assessed using histone H1 as a substrate. Our results showed that Cdk5 activity and the number of fragmented Golgi increased significantly after isoflurane exposure. This was accompanied by an increase in neuronal death. Meanwhile, pharmacological inhibition of Cdk5 activity by 8 µM roscovitine alleviated isoflurane-induced Golgi fragmentation and neurotoxicity. Cumulatively, this study shows that aberrant Cdk5 activation-induced Golgi fragmentation is relevant to isoflurane neurotoxicity and indicates that a Cdk5 inhibitor may be a potential therapeutic candidate for the prevention of isoflurane-induced neurotoxicity. Video abstract: http://links.lww.com/WNR/A445.

Does the type of anesthesia really affect the recurrence-free survival after breast cancer surgery?

Background

Although previous studies have suggested that propofol inhibits cancer recurrence and metastasis, the association between anesthetic agents and the recurrence of breast cancer has not been clearly investigated. We compared total intravenous anesthesia and balanced anesthesia with volatile agents to investigate the differences in their effects on recurrence-free survival and overall survival after breast cancer surgery.

Materials and Methods

The electronic medical records of 2,729 patients who underwent breast cancer surgery between November 2005 and December 2010 were retrospectively reviewed to analyze the factors associated with recurrence-free survival after surgery. Cox proportional hazards models were used to identify the risk factors for cancer recurrence and overall mortality after breast cancer surgery.

Results

Data from 2,645 patients were finally analyzed. The recurrence-free survival rate in this study was 91.2%. Tumor-node-metastasis staging exhibited the strongest association with breast cancer recurrence. However, we were unable to identify significant differences between the preventive effects of total intravenous anesthesia and those of volatile agents on postoperative breast cancer recurrence using Cox regression analyses and propensity score matching. Furthermore, the survival probability with regard to postoperative recurrence and mortality showed no significant differences among anesthetic agents.

Conclusions

Our findings suggest that the effects of total intravenous anesthesia are comparable with those of volatile agents with regard to postoperative recurrence-free survival and overall survival in patients with breast cancer.

The Effects of Remifentanil on Expression of High Mobility Group Box 1 in Septic Rats

High mobility group box 1 (HMGB1) is a pivotal mediator of sepsis progression. Remifentanil, an opioid agonist, has demonstrated anti-inflammatory effects in septic mice. However, it is not yet known whether remifentanil affects the expression of HMGB1. We investigated the effects of remifentanil on HMGB1 expression and the underlying mechanism in septic rats. Forty-eight male Sprague-Dawley rats were randomly divided into 3 groups; a sham group, a cecal ligation and puncture (CLP) group, and a CLP with remifentanil treatment (Remi) group. The rat model of CLP was used to examine plasma concentrations of proinflammatory cytokines, tissue HMGB1 mRNA and the activity of nuclear factor (NF)-κB in the liver, lungs, kidneys, and ileum. Pathologic changes and immunohistochemical staining of NF-κB in the liver, lungs, and kidneys tissue were observed. We found that remifentanil treatment suppressed the level of serum interleukin (IL)-6 and tumor necrosis factor (TNF)-α 6 hours after CLP, and serum HMGB1 24 hours after CLP. HMGB1 mRNA levels and the activity of NF-κB in multiple organs decreased by remifentanil treatment 24 hours after CLP. Remifentanil treatment also attenuated nuclear expression of NF-κB in immunohistochemical staining and mitigated pathologic changes in multiple organs. Altogether, these results suggested that remifentanil inhibited expression of HMGB1 in vital organs and release of HMGB1 into plasma. The mechanism was related to the inhibitory effect of remifentanil on the release of proinflammatory cytokines and activation of NF-κB.

Effects of propofol-based total intravenous anesthesia on recurrence and overall survival in patients after modified radical mastectomy: a retrospective study

Background

The optimal combination of anesthetic agent and technique may have an influence on long-term outcomes in cancer surgery. In vitro and in vivo studies suggest that propofol independently reduces migration of cancer cells and metastasis. Thus, the authors retrospectively examined the link between propofol-based total intravenous anesthesia (TIVA) and recurrence or overall survival in patients undergoing modified radical mastectomy (MRM).

Methods

A retrospective analysis of the electronic database of all patients undergoing MRM for breast cancer between January 2007 and December 2008 was undertaken. Patients received either propofol-based TIVA (propofol group) or sevoflurane-based anesthesia (sevoflurane group). We analyzed prognostic factors of breast cancer and perioperative factors and compared recurrence-free survival and overall survival between propofol and sevoflurane groups.

Results

A total of 363 MRMs were carried out during the period of the trial; 325 cases were suitable for analysis (173 cases of propofol group, and 152 cases of sevoflurane group). There were insignificant differences between the groups in age, weight, height, histopathologic results, surgical time, or postoperative treatment (chemotherapy, hormonal therapy, and radiotherapy). The use of opioids during the perioperative period was greater in propofol group than in sevoflurane group. Overall survival was no difference between the two groups. Propofol group showed a lower rate of cancer recurrence (P = 0.037), with an estimated hazard ratio of 0.550 (95% CI 0.311–0.973).

Conclusions

This retrospective study provides the possibility that propofol-based TIVA for breast cancer surgery can reduce the risk of recurrence during the initial 5 years after MRM.

Total Intravenous Versus Inhalation Anesthesia in Patients Undergoing Laparoscopic Cholecystectomies. Effects on Two Proinflammatory Cytokines Serum Levels: Il-32 and TNF-Alfa

Introduction

It has been reported that as compared with total intravenous anesthesia (TIVA), inhalation anesthesia is increasing the postoperative level of proinflammatory interleukins.The aim of the study is to investigate if there is an in-vivo relationship between proinflammatory cytokines, Interleukin-32 (IL-32) and Tumour necrosis factor - α (TNF-α), in patients undergoing laparoscopic cholecystectomies with two different anesthetic techniques, TIVA or inhalation anesthesia.

Material and Methods

Twenty two consecutive patients undergoing laparoscopic cholecystectomies were prospectively randomized into two groups: Group 1: TIVA with target-controlled infusion (TIVA-TCI) (n=11) and Group 2: isoflurane anesthesia (ISO) (n=11). IL-32 and TNF-α were determined before the induction of anesthesia (T1), before incision (T2) and at 2h (T3) and 24h (T4) postoperatively. Our primary outcome was to compare plasma levels of IL-32 and TNF-α concentrations (expressed as area-under-the-curve) over 24 hours between study groups. Our secondary outcome was to establish whether there is a correlation between plasma levels of IL-32 and of TNF-α at each time point between the two groups.

Results

Area-under-the-curve (AUC) of IL-32 plasma concentration was 7.53 in Group 1 (TIVA) versus 3.80 in Group 2 (ISO), p= 1. For TNF-α, AUC of plasma concentration was 733.9 in Group 1 (TIVA) and 668.7 in Group 2 (ISO), p=0.066. There were no significant differences in plasma concentrations of both IL-32 and TNF-α between the groups.

Conclusions

IL-32 expression in response to minor surgery is very low. There were no significant difference between plasma levels of TNF-α and IL-32 after TIVA versus inhalation anesthesia during the first 24 hours postoperatively. Further studies are needed on larger groups to investigate whether there can be a correlation between these interleukins after 2 different anesthetic techniques and the impact of this correlation on postoperative outcome.

Regional anaesthesia and analgesia: relationship to cancer recurrence and survival

Cancer treatment is associated with significant morbidity and mortality. Surgery is a mainstay of treatment for many tumours, and anaesthetists care for cancer patients on a daily basis. Surgery itself induces a stress response and inhibits the immune system, and cancer surgery is associated with the release of tumour cells systemically. Preclinical and clinical studies suggest that the anaesthetics and adjuvants given in the perioperative period can affect cancer recurrence and survival, perhaps tipping the balance in some instances to determine whether cancer progresses or regresses. Retrospective studies have hinted that regional anaesthesia can play a protective role in cancer surgery, but many of these studies are small and subject to bias. We eagerly await the results of several large, randomized controlled trials examining the impact of regional anaesthesia and analgesia on cancer recurrence and survival.

Effects of propofol and isoflurane on haemodynamics and the inflammatory response in cardiopulmonary bypass surgery

Cardiopulmonary bypass (CPB) causes reperfusion injury that when most severe is clinically manifested as a systemic inflammatory response syndrome. The anaesthetic propofol may have anti-inflammatory properties that may reduce such a response. We hypothesised differing effects of propofol and isoflurane on inflammatory markers in patients having CBR Forty patients undergoing elective CPB were randomised to receive either propofol or isoflurane for maintenance of anaesthesia. CRP, IL-6, IL-8, HIF-1α (ELISA), CD11 and CD18 expression (flow cytometry), and haemoxygenase (HO-1) promoter polymorphisms (PCR/electrophoresis) were measured before anaesthetic induction, 4 hours post-CPB, and 24 hours later. There were no differences in the 4 hours changes in CRP, IL-6, IL-8 or CD18 between the two groups, but those in the propofol group had higher HIF-1α (P = 0.016) and lower CD11 expression (P = 0.026). After 24 hours, compared to the isoflurane group, the propofol group had significantly lower levels of CRP (P < 0.001), IL-6 (P < 0.001) and IL-8 (P < 0.001), with higher levels CD11 (P = 0.009) and CD18 (P = 0.002) expression. After 24 hours, patients on propofol had increased expression of shorter HO-1 GT(n) repeats than patients on isoflurane (P = 0.001). Use of propofol in CPB is associated with a less adverse inflammatory profile than is isofluorane, and an increased up-regulation of HO-1. This supports the hypothesis that propofol has anti-inflammatory activity.

Effect of Propofol and Desflurane on Immune Cell Populations in Breast Cancer Patients: A Randomized Trial

Several factors can affect the perioperative immune function. We evaluated the effect of propofol and desflurane anesthesia on the surgery-induced immune perturbation in patients undergoing breast cancer surgery. The patients were randomly assigned to receive propofol (n = 20) or desflurane (n = 20) anesthesia. The total and differential white blood cell counts were determined with lymphocyte subpopulations before and 1 hr after anesthesia induction and at 24 hr postoperatively. Plasma concentrations of interleukin (IL)-2 and IL-4 were also measured. Both propofol and desflurane anesthesia preserved the IL-2/IL-4 and CD4(+)/CD8(+) T cell ratio. Leukocytes were lower in the propofol group than in the desflurane group at 1 hr after induction (median [quartiles], 4.98 [3.87-6.31] vs. 5.84 [5.18-7.94] 10(3)/µL) and 24 hr postoperatively (6.92 [5.54-6.86] vs. 7.62 [6.22-9.21] 10(3)/µL). NK cells significantly decreased 1 hr after induction in the propofol group (0.41 [0.34-0.53] to 0.25 [0.21-0.33] 10(3)/µL), but not in the desflurane group (0.33 [0.29-0.48] to 0.38 [0.30-0.56] 10(3)/µL). Our findings indicate that both propofol and desflurane anesthesia for breast cancer surgery induce a favorable immune response in terms of preservation of IL-2/IL-4 and CD4(+)/CD8(+) T cell ratio in the perioperative period. With respect to leukocytes and NK cells, desflurane anesthesia is associated with less adverse immune responses than propofol anesthesia during surgery for breast cancer. (Clinical trial registration at https://cris.nih.go.kr/cris number: KCT0000939).

Anesthesia, surgical stress, and "long-term" outcomes

An increasing body of evidence shows that the choice of anesthetic can strongly influence more than simply the quality of anesthesia. Regional and general anesthesia have often been compared to ascertain whether one provides benefits through dampening the stress response or harms by accelerating cancer progression. Regional anesthesia offers considerable advantages, by suppressing cortisol and catecholamine levels and reducing muscle breakdown postoperatively. It also has less immunosuppressive effect and potentially reduces the proinflammatory cytokine response. As such, vital organ functions (e.g., brain and kidney) may be better preserved with regional anesthetics, however, further study is needed. Volatile general anesthetics appear to promote cancer malignancy in comparison to regional and intravenous general anesthetics, and reduce the body's ability to act against cancer cells by suppression of natural killer cell activity. There is not sufficient evidence to support an alteration of current clinical practice, however, further research into this area is warranted due to the potential implications elicited by current studies.

Biomarkers of inflammation in major vascular surgery: a prospective randomised trial

BACKGROUND

Surgery induces inflammation and pro-inflammatory cytokines are associated with post-operative complications. In cardiac surgery, it has been shown that volatile anaesthetics have cardioprotective properties. We explored whether sevoflurane affects the pro-inflammatory response favourably compared with total intravenous anaesthesia (TIVA) after surgery.

METHODS

We measured monocyte chemotactic protein 1 (MCP-1), matrix metalloproteinase 9 (MMP-9), C-reactive protein (CRP), vascular cell adhesion molecule 1 (VCAM-1), interleukin (IL)-6 and IL-8 perioperatively and evaluated if the anaesthetic regimen affected these mediators. Our hypothesis was that sevoflurane-based anaesthesia is associated with a reduced release of biomarkers of inflammation compared with TIVA with propofol/remifentanil.

RESULTS

In the total population, MCP-1, MMP-9, IL-6 and IL-8 increased 30 min after arrival intensive care unit, compared with before surgery (P < 0.001), whereas CRP and VCAM-1 transiently declined (P < 0.001). From 30 min after arrival intensive care unit to 1st post-operative day, MCP-1 and IL-6 levels declined (P < 0.001), CRP and VCAM-1 increased (P < 0.001), whereas MMP-9 and IL-8 were not significantly altered. Pre-operatively there were no significant differences in any variables between the two anaesthetic groups. Lower levels of MCP-1 and IL-8 (P < 0.001) and higher levels of IL-6 and MMP-9 (P = 0.003) were found in the sevoflurane group, compared with the TIVA group 30 min post-operatively. CRP and VCAM-1 levels did not differ. There were no significant differences between the two anaesthetic groups before surgery or at 1st post-operative day.

CONCLUSION

We found an inflammatory response during the observation period, which was modified by the anaesthetic regimen in the early phase. This short-lasting difference is probably too short to support a cardioprotective effect of sevoflurane compared with TIVA in open abdominal aortic surgery.

Remifentanil attenuates lipopolysaccharide-induced acute lung injury by downregulating the NF-κB signaling pathway

Remifentanil significantly represses cell immune responses and influences neutrophil migration through endothelial cell monolayers. The present study determines the beneficial effects of remifentanil and the mechanisms by which it attenuates lipopolysaccharide (LPS)-induced acute lung injury (ALI). Rats were intratracheally instilled with 2 mg/kg LPS to induce ALI. Results showed that remifentanil could resolve lung injury, as evidenced by remarkable decreases in lung edema (wet-to-dry weight ratio), neutrophil infiltration (myeloperoxidase activity), and pulmonary permeability [total number of cells and protein concentrations in bronchoalveolar lavage fluid (BALF)]. Remifentanil also attenuated the concentrations of proinflammatory cytokines tumor necrosis factor alpha, interleukin-1β, and interleukin-6 in BALF, as well as effectively repressed the activation of nuclear factor-kappaB (NF-κB), which has been associated with the inhibition of IκBα degradation.These results suggest that remifentanil may be a suitable treatment for LPS-induced ALI. Remifentanil exerts beneficial effects on the inhibition of proinflammatory cytokine production by downregulating the NF-κB pathway.

Effects of remifentanil on in-hospital mortality and length of stay following clipping of intracranial aneurysm: a propensity score-matched analysis

BACKGROUND

Remifentanil is an ultrashort-acting µ-opioid receptor agonist and is especially suitable for neuroanesthesia. We previously reported that general anesthesia with remifentanil for brain tumor resection was associated with lower postoperative mortality and shorter postoperative length of stay (LOS) when compared with surgeries without remifentanil. This phenomenon may also exist during clipping of intracranial aneurysms (ICAs), where brain tissue frequently suffers ischemia and reperfusion injury. We performed a propensity score-matching study to compare in-hospital mortality and postoperative LOS with and without remifentanil in such patients.

METHODS

We used the Diagnosis Procedure Combination inpatient database in Japan that includes 926 acute care hospitals to identify patients who underwent clipping of ICAs under general anesthesia between July and December 2007.

RESULTS

Of the 4502 patients who underwent ICA clipping, 1380 propensity-matched pairs (n=2760) were included for outcome comparison. The remifentanil group had significantly lower in-hospital mortality than the nonremifentanil group (4.2% vs. 7.7%; P<0.001). Use of remifentanil was an independent factor for lower in-hospital mortality (odds ratio=0.52; 95% confidence interval, 0.37-0.74; P<0.001). By contrast, postoperative LOS did not differ significantly between the 2 groups. There was no difference in the occurrence of postoperative complications except for hydrocephalus, which was more common with remifentanil.

CONCLUSIONS

This retrospective observational study demonstrated a possible relationship between the use of remifentanil for neuroanesthesia and reduced mortality of patients undergoing clipping of ICAs with open craniotomy. Prospective interventional studies are necessary to confirm this relationship.

Impact of Volatile Anesthetics on Oxidative Stress and Inflammation

The safety of anesthesia, which is an important step for surgery, can be determined by its impact on oxidative stress and inflammation. The effects of volatile anesthetics such as isoflurane and sevoflurane on oxidative stress and inflammation are reviewed in various (1) cell lines, (2) rodents, and (3) human studies. Isoflurane and sevoflurane are reported to have antioxidant and anti-inflammatory effects in all cells with exception of neuronal cell lines. In addition, various animal studies have indicated that isoflurane and sevoflurane were not only safe but also reduced oxidative stress and inflammation in rodent models. In human studies, oxidative stress, inflammation, and DNA damage were not affected by isoflurane and sevoflurane in patients undergoing minor incision surgeries. On the other hand, elevated oxidative stress, inflammation, and DNA damage have been observed in patients undergoing major surgeries such as abdominal and orthopedic surgeries, hysterectomy, cholecystectomy, and thoracotomy. Although impact of anesthetics on oxidative stress and inflammation is still not clear due to the variations of patients' health conditions, types of surgery and the quantities of anesthetics, isoflurane, and sevoflurane can be considered safe anesthetics with respect to their effect on oxidative stress and inflammation in subjects undergoing minor surgery. Continuous effort evaluating the safety of anesthesia in various aspects is required.

Cancer surgery: how may anesthesia influence outcome?

OBJECTIVE

To review the published literature regarding the effects of anesthesia on cancer surgery to prevent tumor cell proliferation/migration or induce apoptosis.

BACKGROUND

Surgery is the main treatment for potentially curable solid tumors, but most cancer-related deaths in patients who have received previous surgical treatment are caused by metastatic disease. There is increasing evidence that anesthetic technique has the potential to affect long-term outcome after cancer surgery.

METHODS

This work reviews the English published literature that was obtained by performing a search of the PubMed database up to January 2014. We selected articles that provided evidence or reviewed the possible actions of anesthetics on cancer cells or the influence of anesthesia in recurrence/outcome.

RESULTS

Inhaled anesthetics induce immunosuppression and activate inflammatory cascade activation, whereas propofol has a protective action. Opioids might promote cancer recurrence and metastasis. In vitro and in vivo studies have demonstrated that local anesthetics inhibit proliferation and migration of cancer cells and induce apoptosis.

CONCLUSIONS

Anesthesiologists should follow current best clinical practice and include all strategies that effectively decrease pain and attenuate stress. Regional anesthesia and multimodal analgesia, adding anti-inflammatory drugs, play an unquestionable role in the control of perioperative pain and may improve recurrence-free survival.