Differences between Total Intravenous Anesthesia and Inhalation Anesthesia in Free Flap Surgery of Head and Neck Cancer

Effect of total intravenous-based immediate extubation on patient outcomes in adult liver transplantation: A retrospective cohort study

Background

Although step-down emergence and extubation are universally practiced after liver transplantation (LT), prolonged mechanical ventilation and positive end-expiratory pressure may enhance predisposition to ventilator-associated complications and may be associated with inferior outcomes.

Methods

We screened 339 patients who underwent LT in this retrospective cohort study. After propensity score matching, 35 patients in Group F (total intravenous-based immediate extubation, TIIE) and 107 patients in Group C (balanced anesthesia with step-down extubation) with balanced and comparable pre- and intraoperative profiles were selected for analysis. Patients in Group F received propofol- and remifentanil-based total intravenous anesthesia, followed by immediate tracheal extubation. Patients in Group C received sevoflurane-based balanced anesthesia and were step-down extubated in the intensive care unit. The primary outcomes were postoperative respiratory support time and length of postoperative ICU stay. Other postoperative outcomes were compared between the two groups.

Results

Group F had significantly shorter postoperative respiratory support time than Group C (median, 0.08 vs 17 h; P < 0.001). The duration of postoperative intensive unit care stay in Group F was significantly shorter than that in Group C (mean, 5.84 vs 7.08 days; P = 0.019). Group F had a lower incidence of bacterial infection (20.0 % vs 42.1 %; P = 0.019) than Group C. No significant differences in continuous renal replacement therapy use (2.86 % vs 13.08 %; odds ratio, 0.195; P = 0.088), early mortality rate, percentage reduction of bilirubin, the incidence of exploratory laparotomy, pneumonia, or thrombosis were observed between groups.

Conclusion

TIIE is safe, effective, and associated with a lower incidence of postoperative bacterial infection.

Minimizing Narcotic Use in Rhinoplasty: An Updated Narrative Review and Protocol

Opioids are commonly used to reduce pain after surgery; however, there are severe side effects and complications associated with opioid use, with addiction being of particular concern. Recent practice has shifted to reduce opioid consumption in surgery, although a specific protocol for rhinoplasty is still in progress. This paper aims to expand on the protocol previously established by the senior author based on updated evidence and details. This was accomplished by first high-lighting and summarizing analgesic agents with known opioid-reducing effects in the surgical field, with a particular focus on rhinoplasty, then compiling these analgesic options into a recommended protocol based on the most effective timing of administration (preoperative, intraoperative, postoperative). The senior author's previous article on the subject was referenced to compile a list of analgesic agents of importance. Each analgesic agent was then searched in PubMed in conjunction with "rhinoplasty" or "opioid sparing" to find relevant primary sources and systematic reviews. The preferred analgesic agents included, as follows: preoperative, 1000 mg oral acetaminophen, 200 mg of oral celecoxib twice daily for 5 days, and 1200 mg oral gabapentin; intraoperative, 0.75 μg/kg of intravenous dexmedetomidine and 1-2 mg/kg injected lidocaine with additional 2-4 mg/kg per hour or 1.5 cc total bupivacaine nerve block injected along the infraorbital area bilaterally and in the subnasal region; and postoperatively, 5 mg oral acetaminophen and 400 mg of oral celecoxib. When choosing specific analgesic agents, considerations include potential side effects, contraindications, and the drug-specific mode of administration.

Practice Trends and Evidence-Based Practice in Microvascular Reconstruction

Microvascular and free flap reconstruction are important to the otolaryngology-head and neck surgery practice. Herein, the reader will find an up-to-date discussion of various evidence-based practice trends related to microvascular surgery, including surgical techniques, anesthetic and airway considerations, free flap monitoring and troubleshooting, surgical efficiency, and both patient-related and surgeon-related risk factors that may affect outcomes.

Total Intravenous Anesthesia Versus Inhaled Sevoflurane in Obstructive Sleep Apnea Surgery: A Randomized Controlled Trial

OBJECTIVE

Specific guidelines regarding an optimal general anesthesia (GA) approach to obstructive sleep apnea (OSA) patients remain undefined. Literature comparing the efficacy of total intravenous anesthesia (TIVA) and inhalational anesthesia in this population is sparse. We hypothesize that OSA patients receiving TIVA will experience reduced recovery times and other improved post-surgical outcomes.

STUDY DESIGN

Randomized controlled trial.

METHODS

Adult OSA patients undergoing upper airway surgery (hypoglossal nerve stimulation [HNS], nasal, or palate surgery) from February 2020-December 2020 were included. A post-anesthesia care unit (PACU) nursing survey documented patients' alertness, pain, oxygen supplementation, and postoperative nausea and vomiting from PACU arrival to 2 hours. Perioperative timepoints from the electronic medical record (EMR) and a nurse-estimated Phase I recovery time were collected.

RESULTS

One hundred eleven patients were included (46 TIVA and 65 inhalational anesthesia). Per EMR-recorded timepoints, TIVA patients undergoing HNS and palate surgery experienced Phase I Time reductions of 12.5 min (p = 0.042) and 27.5 min (p = 0.016), respectively. Per the PACU survey, TIVA patients undergoing any surgery, HNS, or palate surgery experienced nurse-estimated Phase I Time reductions of 16.5 min (p = 0.004), 12.5 min (p = 0.031), and 38.5 min (p = 0.024), respectively. Overall, TIVA patients experienced higher alertness and pain ratings, and lower oxygen supplementation requirements from PACU arrival to 30 min (p < 0.05).

CONCLUSION

Patients with OSA receiving TIVA for GA maintenance during upper airway procedures experienced reduced recovery times and oxygen supplementation requirements, and a more rapid return to alertness. Future work toward developing optimized anesthetic guidelines for OSA patients is merited.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:984-992, 2023.

Effect of Total Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Microvascular Reconstruction for Head and Neck Cancer: A Randomized Clinical Trial

Importance

Free flap surgery is a lengthy procedure with massive tissue destruction and reconstruction, which makes postoperative pulmonary complications (PPCs) a noticeable issue among patients with head and neck cancer. Propofol-based total intravenous anesthesia (TIVA) has better survival outcomes than inhalational anesthesia (INH) in several types of cancer surgery. A previous retrospective study found that patients in the TIVA group had a lower PPC rate, which may be correlated with a lower intraoperative fluid requirement. We hypothesize that the protective effect remains among patients undergoing free flap surgery for head and neck cancer in a prospective and goal-directed fluid therapy setting.

Objective

To assess the effect of TIVA vs INH on PPCs in patients undergoing microvascular reconstruction for head and neck cancer.

Design, Setting, and Participants

This prospective, 2-arm, randomized clinical trial was conducted at a tertiary hospital in Taiwan; a total of 78 patients 18 years and older with American Society of Anesthesiologists physical status classification 1 to 3 who were scheduled for elective free flap surgery under general anesthesia were included. The trial started in October 2017, completed in October 2019, and finished analysis in January 2022.

Interventions

Patients were enrolled and randomized to the TIVA or INH group. All patients received goal-directed fluid therapy and hemodynamic management if they had a mean arterial pressure (MAP) below 75 mm Hg or a reduction of 10% from baseline MAP.

Main Outcomes and Measures

The primary outcome was a composite of PPCs. The secondary outcomes were the differences in intraoperative hemodynamic values (mean arterial pressure, MAP; cardiac index, CI; systemic vascular resistance index, SVRI; and stroke volume variation, SVV).

Results

A total of 70 patients (65 men [93%]; 5 women [7%]) completed the trial; median (IQR) age was 52.0 (48-59) years in the TIVA group and 57.0 (46-64) years in the INH group. The demographic characteristics were similar between the 2 groups, except that patients in the TIVA group had a slightly lower body mass index. Patients in the TIVA group had a lower risk of developing PPCs (unadjusted odds ratio, 0.25; 95% CI, 0.08-0.80). The TIVA group had significantly higher MAP, lower CI, and higher SVRI than the INH group after the third hour of monitoring. The TIVA group showed a relatively stable hourly MAP, CI, SVRI, and SVV across time points, while the INH group showed a more varying pattern. The generalized estimating equation showed no clinical differences in the trend of hemodynamic parameters across time between groups.

Conclusions and Relevance

In this randomized clinical trial, using propofol-based TIVA reduced the incidence of PPCs in free flap surgery. This finding may be related to more stable hemodynamic manifestations and a lower total balance of fluid throughout the surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03263078.

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.

Anaesthetic implications of free-flap microvascular surgery for head and neck malignancies – A relook

Head and neck free-flap microvascular surgery is a type of surgery where multiple anaesthetic factors play a very important role in the outcome of the surgery while the conduct of anaesthesia itself may be quite challenging for the anaesthesiologist. In microvascular reconstruction of head and neck malignancies, flaps are used to reconstruct a primary defect formed by wide local excision. A free flap is raised after removing the neurovascular pedicle from the donor site and transplanting it by microvascular anastomosis to the new location. This gives rise to a secondary defect which is then repaired by direct suture or skin graft. The anaesthesiologist’s role includes optimizing the physiological conditions for the survival of the flap while decreasing morbidity at the same time. Failure of the free flap is attributed to numerous causes. This is an attempt to highlight them along with discussion of the anaesthesia-related issues that are faced during this type of surgery. The various pre-, intra- and postoperative factors affecting flap survival and overall postoperative outcome in the patient are discussed here.

New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients

Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.

Which Anesthesia Regimen Is Best to Reduce Pulmonary Complications After Head and Neck Surgery?

OBJECTIVES/HYPOTHESIS

The differences between intravenous and inhalation anesthesia in clinical postoperative pulmonary complications (PPCs) have been studied in cardiac and lung resection surgery. Clinical evidence for the effects of these two anesthetics on PPCs in other types of surgery is still missing. We aimed to assess the impact of sevoflurane and propofol on the incidence of PPCs in patients undergoing surgery for head and neck cancer.

STUDY DESIGN

Double-blind, randomized, controlled trial.

METHODS

We assigned 220 adults at intermediate-to-high risk of PPCs scheduled for head and neck cancer surgery with radial forearm or fibular flap reconstruction to either propofol or sevoflurane as a general anesthetic. The occurrence of pulmonary complications according to the Clavien-Dindo score was defined as the primary (within 7 days after surgery) outcome.

RESULTS

The PPC incidence during 7 days after surgery was 32.4% and 18.2% in the propofol and sevoflurane groups, respectively (P = .027). The corresponding incidence of PPCs in patients who underwent tracheotomy at the end of surgery in the two groups was 44.8% and 24.5%, respectively (P = .030). In addition, the Clavien-Dindo classification showed significant differences between groups in minor complications (grades I and II) but not in major complications (grades III-V).

CONCLUSIONS

Compared with intravenous anesthesia, the administration of sevoflurane reduces the incidence of minor PPCs (grades I and II) in moderate- and high-risk patients who have undergone tracheotomy after head and neck cancer surgery with radial forearm or fibular flap reconstruction.

LEVEL OF EVIDENCE

2 Laryngoscope, 131:E108-E115, 2021.

Anesthetic Strategies in Oncological Surgery: Not Only a Simple Sleep, but Also Impact on Immunosuppression and Cancer Recurrence

Tumor recurrences or metastases remain a major hurdle in improving overall cancer survival. In the perioperative period, the balance between the ability of the cancer to seed and grow at the metastatic site and the ability of the patient to fight against the tumor (i.e. the host antitumor immunity) may determine the development of clinically evident metastases and influence the patient outcome. Up to 80% of oncological patients receive anesthesia and/or analgesia for diagnostic, therapeutic or palliative interventions. Therefore, anesthesiologists are asked to administer drugs such as opiates and volatile or intravenous anesthetics, which may determine different effects on immunomodulation and cancer recurrence. For instance, some studies suggest that intravenous drugs, such as propofol, may inhibit the host immunity to a lower extent as compared to volatile anesthetics. Similarly, some studies suggest that analgesia assured by local anesthetics may provide a reduction of cancer recurrence rate; whilst on the opposite side, opioids may exert negative consequences in patients undergoing cancer surgery, by interacting with the immune system response via the modulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, or directly through the opioid receptors on the surface of immune cells. In this review, we summarize the main findings on the effects induced by different drugs on immunomodulation and cancer recurrence.

Impact of general anaesthesia on endoplasmic reticulum stress: propofol vs. isoflurane

Background: This study investigated the effects of propofol and isoflurane on endoplasmic reticulum (ER) stress in an animal model under general anaesthesia. Methods: Rats were randomly divided into Propofol and Isoflurane groups. Anaesthesia was maintained with propofol for Propofol group or isoflurane for Isoflurane group during 3 h. ER stress from lymphocytes in blood and tissues was evaluated between two groups after euthanasia. Reactive oxygen species (ROS) from lymphocytes in blood and tissues, and cytokines in blood were also checked. An immunohistochemical assay for ER stress marker from tissues was performed. Results: After anaesthesia, the levels of CCAAT-enhancer-binding protein homologous proteins (CHOP) in blood and liver were significantly higher in Isoflurane group, compared to Propofol group [blood, 31,499 ± 4,934 (30,733, 26,441-38,807) mean fluorescence intensity (MFI) in Isoflurane group vs. 20,595 ± 1,838 (20,780, 18,866-22,232) MFI in Propofol group, p = 0.002; liver, 28,342 ± 5,535 (29,421, 23,388-32,756) MFI in Isoflurane group vs. 20,004 ± 2,155 (19,244, 18,197-22,191) MFI in Propofol group, p = 0.020]. ROS in blood was significantly higher in Isoflurane group, compared to Propofol group. However, cytokines in blood and immunohistochemical assays in tissues were similar between groups. Conclusion: Significant higher of ER stress from blood and liver were observed in rats under anaesthesia with isoflurane, compared to those that received propofol. ROS from blood also showed significant higher under anaesthesia with isoflurane. However, these findings were not associated with any changes in cytokines in blood or immunohistochemical assay in tissues.