1
|
Kampman JM, Hermanides J, Hollmann MW, Gilhuis CN, Bloem WAH, Schraag S, Pradelli L, Repping S, Sperna Weiland NH. Mortality and morbidity after total intravenous anaesthesia versus inhalational anaesthesia: a systematic review and meta-analysis. EClinicalMedicine 2024; 72:102636. [PMID: 38774674 PMCID: PMC11106536 DOI: 10.1016/j.eclinm.2024.102636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/24/2024] Open
Abstract
Background General anaesthesia is provided to more than 300 million surgical patients worldwide, every year. It is administered either through total intravenous anaesthesia, using only intravenous agents, or through inhalational anaesthesia, using volatile anaesthetic agents. The debate on how this affects postoperative patient outcome is ongoing, despite an abundance of published trials. The relevance of this topic has grown by the increasing concern about the contribution of anaesthetic gases to the environmental impact of surgery. We aimed to summarise all available evidence on relevant patient outcomes with total intravenous anaesthesia versus inhalational anaesthesia. Methods In this systematic review and meta-analysis, we searched PubMed/Medline, Embase and Cochrane Central Register of Controlled trials for works published from January 1, 1985 to August 1, 2023 for randomised controlled trials comparing total intravenous anaesthesia using propofol versus inhalational anaesthesia using the volatile anaesthetics sevoflurane, desflurane or isoflurane. Two reviewers independently screened titles, abstracts and full text articles, and assessed risk of bias using the Cochrane Collaboration tool. Outcomes were derived from a recent series of publications on consensus definitions for Standardised Endpoints for Perioperative trials (StEP). Primary outcomes covered mortality and organ-related morbidity. Secondary outcomes were related to anaesthetic and surgical morbidity. This study is registered with PROSPERO (CRD42023430492). Findings We included 317 randomised controlled trials, comprising 51,107 patients. No difference between total intravenous and inhalational anaesthesia was seen in the primary outcomes of in-hospital mortality (RR 1.05, 95% CI 0.67-1.66, 27 trials, 3846 patients), 30-day mortality (RR 0.97, 95% CI 0.70-1.36, 23 trials, 9667 patients) and one-year mortality (RR 1.14, 95% CI 0.88-1.48, 13 trials, 9317 patients). Organ-related morbidity was similar between groups except for the subgroup of elderly patients, in which total intravenous anaesthesia was associated with a lower incidence of postoperative cognitive dysfunction (RR 0.62, 95% CI 0.40-0.97, 11 trials, 3834 patients) and a better score on postoperative cognitive dysfunction tests (standardised mean difference 1.68, 95% CI 0.47-2.88, 9 trials, 4917 patients). In the secondary outcomes, total intravenous anaesthesia resulted in a lower incidence of postoperative nausea and vomiting (RR 0.61, 95% CI 0.56-0.67, 145 trials, 23,172 patients), less emergence delirium (RR 0.40, 95% CI 0.29-0.56, 32 trials, 4203 patients) and a higher quality of recovery score (QoR-40 mean difference 6.45, 95% CI 3.64-9.25, 17 trials, 1835 patients). Interpretation The results indicate that postoperative mortality and organ-related morbidity was similar for intravenous and inhalational anaesthesia. Total intravenous anaesthesia offered advantages in postoperative recovery. Funding Dutch Society for Anaesthesiology (NVA).
Collapse
Affiliation(s)
- Jasper M. Kampman
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | | | | | - Sjoerd Repping
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Healthcare Evaluation and Appropriate Use, National Healthcare Institute, Diemen, the Netherlands
| | - Nicolaas H. Sperna Weiland
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, the Netherlands
| |
Collapse
|
2
|
Pauchard JC, Hafiani EM, Bonnet L, Cabelguenne D, Carenco P, Cassier P, Garnier J, Lallemant F, Pons S, Sautou V, De Jong A, Caillard A. Guidelines for reducing the environmental impact of general anaesthesia. Anaesth Crit Care Pain Med 2023; 42:101291. [PMID: 37562688 DOI: 10.1016/j.accpm.2023.101291] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVE To provide guidelines for reducing the environmental impact of general anaesthesia. DESIGN A committee of ten experts from SFAR and SF2H and SFPC learned societies was set up. A policy of declaration of competing interests was applied and observed throughout the guideline-writing process. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based. METHODS We aimed to formulate recommendations according to the GRADE® methodology for three different fields: anaesthesia vapours and gases; intravenous drugs; medical devices and the working environment. Each question was formulated according to the PICO format (Population, Intervention, Comparator, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology. RESULTS The experts' work on the synthesis and application of the GRADE® method led to the formulation of 17 recommendations. Since the GRADE® method could not be entirely applied to all of the questions, some of the recommendations were formulated as expert opinions. CONCLUSION Based on strong agreement between experts, we produced 17 recommendations designed to guide reducing the environmental impact of general anaesthesia.
Collapse
Affiliation(s)
- Jean-Claude Pauchard
- Ramsay Santé, Member of Société Française d'Anesthésie Réanimation (SFAR) Substainable Development Committee, Clinique Aguiléra, Biarritz, France.
| | - El-Madhi Hafiani
- Department of Anaesthesia, Resuscitation and Perioperative Medicine, DMU DREAM - Tenon Hospital, AP-HP Sorbonne University, Paris, France.
| | - Laure Bonnet
- Department of Anesthesia and Intensive Care, Centre Hospitalier Princess Grace, Monaco
| | | | - Philipe Carenco
- Hygiene Department CHU de Nice, Nice, France; CPias PACA, Marseille, France; AFNOR, La Plaine Saint-Denis, France; Comité Européen de Normalisation, Brussels, Belgium; Bureau de Normalisation de l'Industrie Textile et de l'Habillement (BNITH), domaine des textiles en santé, Paris, France
| | - Pierre Cassier
- Institute of Infectious Agents, Hospices Civils de Lyon, Lyon, France; CIRI, Centre International de Recherche en Infectiologie, Université de Lyon, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, Lyon, France
| | - Jérémie Garnier
- Department of Anesthesia and Intensive Care Unit, CHU Amiens-Picardie, 1 Rond-Point du Pr Christian Cabrol, 80054 Amiens Cedex 1, France
| | - Florence Lallemant
- Department of Anesthesia and Intensive Care Unit, CHU Lille, F-59000 Lille, France; CHU Lille, Pôle des Urgences, F-59000 Lille, France
| | - Stéphanie Pons
- DMU DREAM, Department of Anesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière, Paris, France
| | - Valérie Sautou
- Clermont Auvergne University, Clermont Auvergne INP, CNRS, CHU Clermont Ferrand, ICCF, F-63000 Clermont-Ferrand, France
| | - Audrey De Jong
- PhyMedExp, Montpellier University, INSERM, CNRS, CHU Montpellier, France; Department of Anesthesia and Intensive Care Unit, St-Eloi Hospital, France
| | - Anaïs Caillard
- Department of Anesthesia and Intensive Care Unit, CHU Brest, Cavale Blanche Hospital, France; ORPHY, EA 4324, France
| |
Collapse
|
3
|
Cukierman DS, Cata JP, Gan TJ. Enhanced recovery protocols for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:285-303. [PMID: 37938077 DOI: 10.1016/j.bpa.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23 h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery.
Collapse
Affiliation(s)
- Daniel S Cukierman
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Tong Joo Gan
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.
| |
Collapse
|
4
|
Guevara-Farias JC, Rincón-Valenzuela DA, Gómez-Ardila C. Comparison of direct costs associated with the use of balanced general anesthesia and total intravenous anesthesia (TIVA) techniques. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.5554/22562087.e1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Healthcare costs are increasing against the backdrop of scarce resources. Surgical procedures are an important part of healthcare spending, and the cost of anesthetic techniques is relevant as part of the total cost of care and it is a potential target for expenditure optimization. Although important economic differences have been reported internationally for general anesthesia options, there are no publications in Colombia that compare current costs and allow for informed and financially responsible decision-making.
Objective: To quantify and compare direct costs associated with the various general anesthesia options most frequently used at the present time.
Methods: Cost minimization analysis based on a theoretical model of balanced general anesthesia using isoflurane, sevoflurane, desflurane in combination with remifentanil, and TIVA (propofol and remifentanil). Initial results were obtained using a deterministic simulation method and a sensitivity analysis was performed using a Monte Carlo simulation.
Results: The average total cost per case for the different anesthetic techniques was COP 126381 for sevoflurane, COP 97706 for isoflurane, COP 288605 for desflurane and COP 222 960 for TIVA.
Conclusions: Balanced general anesthesia with desflurane is the most costly alternative, 1.2 times more expensive than TIVA, and 2 and 3 times more costly than balanced anesthesia with sevoflurane and isoflurane, respectively. TIVA ranks second with a cost 1.8 times higher than balanced anesthesia with sevoflurane and 2.5 times higher than balanced anesthesia with isoflurane.
Collapse
|
5
|
Dai M, Lv P, Hu X, Zheng B. Effect of remifentanil combined with sevoflurane inhalation anesthesia on coagulation function and postoperative recovery of patients undergoing endoscopic selective varices devascularization. Am J Transl Res 2021; 13:9764-9770. [PMID: 34540107 PMCID: PMC8430125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the effect of remifentanil combined with sevoflurane inhalation anesthesia on coagulation function and postoperative recovery of patients undergoing endoscopic selective varices devascularization (ESVD). METHODS Altogether 116 patients undergoing ESVD in our hospital were randomly divided into two groups. The control group received propofol combined with remifentanil anesthesia, while the observation group received remifentanil combined with sevoflurane inhalation anesthesia. RESULTS There was no statistical difference in coagulation function indexes between the control group and the observation group (P>0.05), and the clinical anesthesia effect of the observation group was better (P<0.001). Five minutes after intubation, compared with the control group, the clinical stress response index was better (all P<0.001), the quality of anesthesia recovery was higher (all P<0.001), the heart rate was better after anesthesia (P<0.001), and the incidence of adverse reactions was higher (P<0.01) in the observation group. CONCLUSION Compared with remifentanil combined with propofol anesthesia, remifentanil combined with sevoflurane inhalation anesthesia for ESVD can effectively improve the clinical anesthesia effect, improve the quality of anesthesia recovery, and reduce stress reactions, but the incidence of adverse reactions is increased. Therefore the clinical application still needs to be strengthened.
Collapse
Affiliation(s)
- Maolin Dai
- Department of Anesthesiology, Rongchang People’s HospitalChongqing City, China
| | - Pin Lv
- Department of Anesthesiology, Rongchang People’s HospitalChongqing City, China
| | - Xiaojun Hu
- Department of Orthopedics, Rongchang People’s HospitalChongqing City, China
| | - Binwu Zheng
- Department of Anesthesiology, Rongchang People’s HospitalChongqing City, China
| |
Collapse
|
6
|
Kampmeier T, Rehberg S, Omar Alsaleh AJ, Schraag S, Pham J, Westphal M. Cost-Effectiveness of Propofol (Diprivan) Versus Inhalational Anesthetics to Maintain General Anesthesia in Noncardiac Surgery in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:939-947. [PMID: 34243837 DOI: 10.1016/j.jval.2021.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/17/2020] [Accepted: 01/07/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES It is not known whether using propofol total intravenous anaesthesia (TIVA) to reduce incidence of postoperative nausea and vomiting (PONV) is cost-effective. We assessed the economic impact of propofol TIVA versus inhalational anesthesia in adult patients for ambulatory and inpatient procedures relevant to the US healthcare system. METHODS Two models simulate individual patient pathways through inpatient and ambulatory surgery with propofol TIVA or inhalational anesthesia with economic inputs from studies on adult surgical US patients. Efficacy inputs were obtained from a meta-analysis of randomized controlled trials. Probabilistic and deterministic sensitivity analyses assessed the robustness of the model estimates. RESULTS Lower PONV rate, shorter stay in the post-anesthesia care unit, and reduced need for rescue antiemetics offset the higher costs for anesthetics, analgesics, and muscle relaxants with propofol TIVA and reduced cost by 11.41 ± 10.73 USD per patient in the inpatient model and 11.25 ± 9.81 USD in the ambulatory patient model. Sensitivity analyses demonstrated strong robustness of the results. CONCLUSIONS Maintenance of general anesthesia with propofol was cost-saving compared to inhalational anesthesia in both inpatient and ambulatory surgical settings in the United States. These economic results support current guideline recommendations, which endorse propofol TIVA to reduce PONV risk and enhance postoperative recovery.
Collapse
Affiliation(s)
- Tim Kampmeier
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany.
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
| | | | - Stefan Schraag
- Department of Perioperative Medicine, Golden Jubilee National Hospital, Clydebank, Scotland, UK
| | - Jenny Pham
- Medical, Clinical, and Regulatory Affairs, Fresenius Kabi AG, Bad Homburg, Germany
| | - Martin Westphal
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Muenster, Muenster, Germany and Fresenius Kabi AG, Bad Homburg, Germany
| |
Collapse
|
7
|
Li J, Wei YY, Zhang DH. Postoperative recovery of patients with differential requirements for sevoflurane after abdominal surgery: A prospective observational clinical study. Medicine (Baltimore) 2021; 100:e24842. [PMID: 33663105 PMCID: PMC7909113 DOI: 10.1097/md.0000000000024842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/26/2021] [Indexed: 02/05/2023] Open
Abstract
An association between animals and volatile anaesthetic requirements has been shown; however, evidence related to the postoperative outcome of human patients is lacking. Our aim was to investigate whether there is a difference in the requirement for sevoflurane among people undergoing gastrointestinal surgery.We observed 390 adult patients who underwent gastrointestinal surgery with an American Society of Anesthesiologists physical status of I or II with an expected surgery duration of > 2 hours. We used the bispectral index (BIS) to guide the regulation of end-tidal sevoflurane concentration (ETsevo). The mean ETsevo from 20 minutes after endotracheal intubation to 2 hours after the start of surgery was calculated for all patients. Differential sevoflurane requirements were identified according to ETsevo. The BIS, ETsevo, heart rate, mean arterial pressure, dose of sufentanil and cisatracurium, tracheal extubation time, incidence of intraoperative awareness, and incidence of postoperative nausea and vomiting were compared between patients with a low requirement for sevoflurane (group L) and patients with a high requirement for sevoflurane (group H).The mean ETsevo of the 390 patients was 1.55% ± 0.26%. Based on our definition, patients with an ETsevo of < 1.29% were allocated to the low requirement group (group L; n = 69), while patients with an ETsevo of > 1.81% were allocated to the high requirement group (group H; n = 78). The ETsevo of group L was significantly lower than the ETsevo of group H (1.29% ± 0.014% vs 1.82% ± 0.017%, P < .001). There was no significant difference in the ETsevo, BIS, heart rate, mean arterial pressure, dose of sufentanil and cisatracurium, tracheal extubation time, incidence of intraoperative awareness, and incidence of postoperative nausea and vomiting. The tracheal extubation time in the L group was significantly shorter than that in the H group. No intraoperative awareness occurred.There was a significant difference in the requirement for sevoflurane in adult patients. The tracheal extubation time in group L was significantly shorter than that in group H.
Collapse
Affiliation(s)
- Jia Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yi Yong Wei
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Dong Hang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
8
|
Affiliation(s)
- Matthew J Meyer
- From the Department of Anesthesiology, University of Virginia (UVA), UVA Health, Charlottesville, Virginia
| |
Collapse
|
9
|
|
10
|
Lauder GR, Thomas M, von Ungern-Sternberg BS, Engelhardt T. Volatiles or TIVA: Which is the standard of care for pediatric airway procedures? A pro-con discussion. Paediatr Anaesth 2020; 30:209-220. [PMID: 31886922 DOI: 10.1111/pan.13809] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 12/21/2022]
Abstract
Anesthesia for pediatric airway procedures constitutes a true art form that requires training and experience. Communication between anesthetist and surgeon to establish procedure goals is essential in determining the most appropriate anesthetic management. But does the mode of anesthesia have an impact? Traditionally, inhalational anesthesia was the most common anesthesia technique used during airway surgery. Introduction of agents used for total intravenous anesthesia (TIVA) such as propofol, short-acting opioids, midazolam, and dexmedetomidine has driven change in practice. Ongoing debates abound as to the advantages and disadvantages of volatile-based anesthesia versus TIVA. This pro-con discussion examines both volatiles and TIVA, from the perspective of effectiveness, safety, cost, and environmental impact, in an endeavor to justify which technique is the best specifically for pediatric airway procedures.
Collapse
Affiliation(s)
- Gillian R Lauder
- Department of Anesthesia, BC Children's Hospital, Vancouver, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Mark Thomas
- Department of Anaesthesia, Great Ormond St Hospital, London, UK
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Medical School, The University of Western Australia, Perth, Australia.,Telethon Kids Institute, Perth, Australia
| | - Thomas Engelhardt
- Department of Anesthesia, McGill University Health Centre, Montreal Children's Hospital, Montreal, QC, Canada
| |
Collapse
|