Volatile Anesthetic Use Versus Total Intravenous Anesthesia for Patients Undergoing Heart Valve Surgery: A Nationwide Population-Based Study.

BACKGROUND: Many studies have suggested that volatile anesthetic use may improve postoperative outcomes after cardiac surgery compared to total intravenous anesthesia (TIVA) owing to its potential cardioprotective effect. However, the results were inconclusive, and few studies have included patients undergoing heart valve surgery. METHODS: This nationwide population-based study included all adult patients who underwent heart valve surgery between 2010 and 2019 in Korea based on data from a health insurance claim database. Patients were divided based on the use of volatile anesthetics: the volatile anesthetics or TIVA groups. After stabilized inverse probability of treatment weighting (IPTW), the association between the use of volatile anesthetics and the risk of cumulative 1-year all-cause mortality (the primary outcome) and cumulative long-term (beyond 1 year) mortality were assessed using Cox regression analysis. RESULTS: Of the 30,755 patients included in this study, the overall incidence of 1-year mortality was 8.5%. After stabilized IPTW, the risk of cumulative 1-year mortality did not differ in the volatile anesthetics group compared to the TIVA group (hazard ratio, 0.98; 95% confidence interval, 0.90-1.07; P = .602), nor did the risk of cumulative long-term mortality (hazard ratio, 0.98; 95% confidence interval, 0.93-1.04; P = .579) at a median (interquartile range) follow-up duration of 4.8 (2.6-7.6) years. CONCLUSIONS: Compared with TIVA, volatile anesthetic use was not associated with reduced postoperative mortality risk in patients undergoing heart valve surgery. Our findings indicate that the use of volatile anesthetics does not have a significant impact on mortality after heart valve surgery. Therefore, the choice of anesthesia type can be based on the anesthesiologists' or institutional preference and experience.

Anesthesia in Combination with Propofol Increases Disease-Free Survival in Bladder Cancer Patients Who Undergo Radical Tumor Cystectomy as Compared to Inhalational Anesthetics and Opiate-Based Analgesia.

BACKGROUND: The effect of anesthetic techniques on cancer recurrence has been the subject of intensive research in the past years, as it affects a large proportion of the population. The use of opioids and halogenated agents in cancer patients during the perioperative period may be related to higher rates of cancer recurrence and reduced disease-free survival. METHODS: This was a prospective study. The sample was composed of 100 patients who underwent a radical cystectomy for infiltrating bladder cancer in a reference center. We compared disease-free survival associated with combined anesthesia versus opiate-based analgesia. The relationship between the administered hypnotic and disease-free survival was also investigated. RESULTS: The median disease-free survival of the patients who received combined anesthesia was 585 (240-1,005) days versus 210 (90-645) days in the other group. A significant difference was observed between the two groups (p = 0.01). Combined analysis of all groups revealed significant differences in disease-free survival between patients who received combined anesthesia with propofol (510 [315-1,545] disease-free days) and those who received sevoflurane and opioids (150 [90-450] disease-free days) (p = 0.02). CONCLUSIONS: Anesthesia may play a crucial role in tumor relapse, as it is administered at the moment of the greatest risk of dissemination: surgical handling of the tumor. Opioids and volatile agents have been related to an increased risk for cancer recurrence. We compared the use of propofol + local anesthesia versus sevoflurane + opioids and also found that disease-free survival was longer among patients who received propofol + local anesthesia. Disease-free survival increases with the use of propofol in combination with epidural anesthesia in patients who undergo surgery for infiltrating bladder cancer.

Distant survival for patients undergoing surgery using volatile versus IV anesthesia for hepatocellular carcinoma with portal vein tumor thrombus: a retrospective study.

BACKGROUND: Whether anesthesia type is associated with the surgical outcome of Hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) remains to be determined. This study aims to investigate the impact of volatile inhalational anesthesia (INHA) versus total IV anesthesia (TIVA) on the survival outcomes in HCC patients with PVTT. METHODS: A cohort of in-patients whom were diagnosed of HCC with PVTT in Eastern Hepatobiliary Surgery Hospital, Shanghai, China, from January 1, 2008 to December 24, 2012 were identified. Surgical patients receiving the INHA and TIVA were screened out. The overall survival (OS), recurrence-free survival (RFS) and several postoperative adverse events were compared according to anesthesia types. RESULTS: A total of 1513 patients were included in this study. After exclusions are applied, 263 patients remain in the INHA group and 208 in the TIVA group. Patients receiving INHA have a lower 5-year overall survival rate than that of patients receiving TIVA [12.6% (95% CI, 9.0 to 17.3) vs. 17.7% (95% CI, 11.3 to 20.8), P = 0.024]. Results of multivariable Cox-regression analysis also identify that INHA anesthesia is significantly associated with mortality and cancer recurrence after surgery compare to TIVA, with HR (95%CI) of 1.303 (1.065, 1.595) and 1.265 (1.040, 1.539), respectively. Subgroup analysis suggested that in more severe cancer patients, the worse outcome related to INHA might be more significant. CONCLUSION: This retrospective analysis identifies that TIVA is associated with better outcomes compared with INHA. Future prospective studies clinical and translational studies are required to verify this difference and investigate underlying pathophysiology.

Effects of Volatile Anesthetics on Mortality and Postoperative Pulmonary and Other Complications in Patients Undergoing Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: It is not known whether modern volatile anesthetics are associated with less mortality and postoperative pulmonary or other complications in patients undergoing general anesthesia for surgery. METHODS: A systematic literature review was conducted for randomized controlled trials fulfilling following criteria: (1) population: adult patients undergoing general anesthesia for surgery; (2) intervention: patients receiving sevoflurane, desflurane, or isoflurane; (3) comparison: volatile anesthetics versus total IV anesthesia or volatile anesthetics; (4) reporting on: (a) mortality (primary outcome) and (b) postoperative pulmonary or other complications; (5) study design: randomized controlled trials. The authors pooled treatment effects following Peto odds ratio (OR) meta-analysis and network meta-analysis methods. RESULTS: Sixty-eight randomized controlled trials with 7,104 patients were retained for analysis. In cardiac surgery, volatile anesthetics were associated with reduced mortality (OR = 0.55; 95% CI, 0.35 to 0.85; P = 0.007), less pulmonary (OR = 0.71; 95% CI, 0.52 to 0.98; P = 0.038), and other complications (OR = 0.74; 95% CI, 0.58 to 0.95; P = 0.020). In noncardiac surgery, volatile anesthetics were not associated with reduced mortality (OR = 1.31; 95% CI, 0.83 to 2.05, P = 0.242) or lower incidences of pulmonary (OR = 0.67; 95% CI, 0.42 to 1.05; P = 0.081) and other complications (OR = 0.70; 95% CI, 0.46 to 1.05; P = 0.092). CONCLUSIONS: In cardiac, but not in noncardiac, surgery, when compared to total IV anesthesia, general anesthesia with volatile anesthetics was associated with major benefits in outcome, including reduced mortality, as well as lower incidence of pulmonary and other complications. Further studies are warranted to address the impact of volatile anesthetics on outcome in noncardiac surgery.

Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in glioblastoma surgery.

BACKGROUND: Previous research has shown that anesthetic techniques can influence patient outcomes following cancer surgery. However, the effects of anesthesia in patients undergoing glioblastoma surgery are still not known. We studied the relationship between the type of anesthesia and patient outcomes following elective glioblastoma surgery. METHODS: This was a retrospective cohort study of patients who underwent elective glioblastoma surgery between January 2008 and December 2018. Patients were grouped according to the anesthesia they received, desflurane or propofol. A Kaplan-Meier analysis was conducted, and survival curves were presented from the date of surgery to death. Univariable and multivariable Cox regression models were used to compare hazard ratios for death after propensity matching. RESULTS: A total of 50 patients (45 deaths, 90.0%) under desflurane anesthesia and 53 patients (38 deaths, 72.0%) under propofol anesthesia were included. Thirty-eight patients remained in each group after propensity matching. Propofol anesthesia was associated with improved survival (hazard ratio, 0.51; 95% confidence interval, 0.30-0.85; P = 0.011) in a matched analysis. Furthermore, patients under propofol anesthesia exhibited less postoperative recurrence than those under desflurane anesthesia (hazard ratio, 0.60; 95% confidence interval, 0.37-0.98; P = 0.040) in a matched analysis. CONCLUSIONS: In this limited sample size, we observed that propofol anesthesia was associated with improved survival and less postoperative recurrence in glioblastoma surgery than desflurane anesthesia. Further investigations are needed to examine the influence of propofol anesthesia on patient outcomes following glioblastoma surgery.

[Fatalities due to nitrous oxide. Complications from mistakes in nitrous oxide supply]. / Lachgasbedingte Todesfälle. Komplikationen durch Verwechslungen in der Lachgaszufuhr.

Despite inspiratory oxygen fraction measurement being regulated by law in the European norm EN 740, fatal errors in nitrous oxide delivery still occur more frequently than expected, especially after construction or repair of gas connection tubes. Therefore, if nitrous oxide is to be used further in a hospital, all technical measures and system procedures should be employed to avoid future catastrophes. Among these are measurement of the inspiratory oxygen fraction (F(I)O(2)) and an automatic limitation of nitrous oxide. Also all anaesthetists involved should be informed about repair or construction of central gas supply tubes. Additionally, more awareness of this problem in daily routine is necessary. Furthermore, a system of detecting and analysing errors in anaesthesia has to be improved in each hospital as well as in the anaesthesia community as a whole. Measures for a better "error culture" could include data exchange between different critical incident reporting systems, analysis of closed claims, and integration of medical experts in examination of recent catastrophes.

Halogenated Agents and Cardiovascular Surgery: Has Mortality Really Decreased?

Halogenated anesthetic agents (desflurane, isoflurane and sevoflurane) may have cardioprotective properties at therapeutic doses against myocardial intraoperative ischemia-reperfusion injury. Cardioprotection mechanisms are related to mitochondrial and anti-apoptotic signaling pathways. Experimentals and human studies have proven that their use may reduce morbidity and mortality in the setting of cardiac surgery, including a reduction in myocardial infarct size and mechanical ventilation needs. In contrast, total intra-venous propofol based anesthesia may be detrimental. In the present review, we show the rationale for the perioperative use of halogenated anesthetics based on mechanisms of action, experimental research and human studies. Considerations and major concerns regarding their use, the present evidence for their use in other areas, such as major non-cardiac surgery and intensive care unit patients, and future perspectives are also discussed.

Mechanisms of Cardioprotection of Halogenated Agents During Extracorporeal Circulation in Cardiac Surgery.

The implementation of cardioprotective strategies involving pre-, intra-, and postoperative interventions is key during cardiac surgery requiring extracorporeal circulation (ECC). The primary goal of this study was to review the physiopathology and protection strategies against myocardial damage secondary to ECC during cardiac surgery. The administration halogenated anesthetics for cardiac anesthesia is common place due to their well-known cardioprotective effects and their capacity to ensure hypnosis. An optimal myocardial protection strategy requires that a comprehensive approach should be adopted to cover pre-, intra-, and post-operative interventions. Pre-conditioning and post-conditioning share numerous pathways, mainly based on mitochondrial signaling, antiapoptotic pathways, and reduced inflammatory mediators. However, volatile anesthetic can also be administered during ECC, in which mechanism of action has been scantly investigated, during this period and its biology is still unknown.

Anesthesia and blood sampling of wild big brown bats (eptesicus fuscus) with an assessment of impacts on survival.

We anesthetized and blood sampled wild big brown bats (Eptesicus fuscus) in Fort Collins, Colorado (USA) in 2001 and 2002 and assessed effects on survival. Inhalant anesthesia was delivered into a specially designed restraint and inhalation capsule that minimized handling and bite exposures. Bats were immobilized an average of 9.1+/-5.1 (SD) min (range 1-71, n=876); blood sample volumes averaged 58+/-12 microl (range 13-126, n=718). We randomly selected control (subject to multiple procedures before release) and treatment (control procedures plus inhalant anesthesia and 1% of body weight blood sampling) groups in 2002 to assess treatment effects on daily survival over a 14-day period for adult female and volant juvenile bats captured at maternity roosts in buildings. We monitored survival after release using passive integrated transponder tag detection hoops placed at openings to selected roosts. Annual return rates of bats sampled in 2001 were used to assess long-term outcomes. Comparison of 14-day maximum-likelihood daily survival estimates from control (86 adult females, 92 volant juveniles) and treated bats (187 adult females, 87 volant juveniles) indicated no adverse effect from anesthesia and blood sampling (juveniles: chi2=22.22, df=27, P>0.05; adults: chi2=9.72, df=18, P>0.05). One-year return rates were similar among adult female controls (81%, n=72, 95% confidence interval [CI]=70-91%), females treated once (82%, n=276, 95% CI=81-84%), and females treated twice (84%, n=50, 95% CI=74-94%). Lack of an effect was also noted in 1-yr return rates of juvenile female controls (55%, n=29, 95% CI=37-73%), juveniles treated once (66%, n=113, 95% CI=58-75%), and juveniles treated twice (71%, n=17, 95% CI=49-92%). These data suggest that anesthesia and blood sampling for health monitoring did not measurably affect survival of adult female and volant juvenile big brown bats.

A comparison of target-controlled infusion versus volatile inhalant anesthesia for heart rate, respiratory rate, and recovery time in a rat model.

We conducted this study to determine whether heart rate, respiratory rate, and recovery time differed significantly between rats receiving target-controlled infusion (TCI) and those under volatile inhalant anesthesia. TCI rats received intravenous propofol at an average effect site concentration of 11.3 microg/ml or propofol plus ketamine (5 mg/ml of propofol) at an average effect site concentration of 8.7 microg/ml. Inhalant anesthesia rats received isoflurane (average, 1.8%) delivered in medical-grade air. We used a tail-clamp response test to determine when a surgical plane of anesthesia was attained. Anesthesia was continued for 1 h from the first negative tail-clamp test. During this time the test was repeated every 10 min to confirm that a surgical plane of anesthesia was being maintained. Anesthesia then was discontinued, and the animals were monitored continuously until they recovered. Average heart rate was higher for rats during anesthesia with isoflurane compared with TCI propofol-ketamine (P =0.0053). Average respiratory rate was higher for TCI regimens compared with isoflurane anesthesia, with male rats having consistently faster respiratory rates than females (P <0.001). Recovery time was longer for both TCI regimens compared with isoflurane (P <0.001). Once venous access was accomplished, TCI anesthesia with propofol or propofol combined with a low dose of ketamine was comparable to an isoflurane inhalant regimen in ease of administration and control of the anesthetic event when used in rats for procedures of 1-h duration. Respiratory rate was increased and recovery time was longer for rats receiving the TCI regimens.

Is isoflurane safer than halothane in equine anaesthesia? Results from a prospective multicentre randomised controlled trial.

REASONS FOR PERFORMING STUDY: Approximately 1 in 100 horses suffer unexpectedly from anaesthetic-related death. Identification and use of the safest anaesthetic drugs should support this aim. Experimental evidence has suggested that isoflurane should be a safer maintenance agent in equine anaesthesia than halothane. HYPOTHESIS: The death rate would be reduced in horses being maintained with isoflurane compared to halothane. METHODS: A multicentre randomised controlled trial was undertaken to compare the effects of isoflurane and halothane for maintenance of equine anaesthesia for all types of operation. Data were analysed from 8242 horses in which anaesthesia was maintained with either halothane or isoflurane using mixed effects logistic regression models. RESULTS: No overall benefit of either drug was detected. However, although not part of the primary hypothesis, data showed that the overall death rate was significantly reduced in horses age 2-5 years with isoflurane and that death from cardiac arrest was also reduced with isoflurane, particularly in high risk cases. CONCLUSIONS AND POTENTIAL RELEVANCE: Halothane remains an acceptable anaesthetic for maintenance of anaesthesia in horses, but isoflurane may be safer in the young horse and in high risk cases.

Anesthetic-related maternal mortality, 1954 to 1985.

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.

[Survey of anaesthesia-related mortality in France: the role of aspiration of gastric contents]. / Enquête mortalité Sfar-Inserm: analyse secondaire des décès par inhalation de liquide gastrique.

Aspiration of gastric contents is a major complication in relation with the practice of anaesthesia. The present article is aimed at describing detailed data related to aspiration which were obtained during the French national survey on anaesthesia-related mortality conducted by both Sfar and CépiDC-Inserm. Information regarding methods of the survey and the main results has been previously published. In brief, the first part of the survey described the number and characteristics of anaesthetic procedures performed in 1996 (denominator). The second survey analysed deaths related to anaesthesia which were identified from death certificates of the calendar year 1999. Because of the numerical importance of aspiration among the causes of deaths, a secondary analysis was undertaken to assess into details factors leading to the occurrence of this complication. Eighty-three cases of death were found related to aspiration, i.e. one-fifth of deaths related completely or partially to anaesthesia, implying a death rate of one for 221,368 general anaesthetic procedures or 4.5 x 10(-6) (95% IC: 0.8 x 10(-6)-14 x 10(-6)). Patients involved were all in a severe clinical condition (ASA> or =3: 92%), very old and often scheduled for urgent abdominal surgery. Two cases of death occurred during colonoscopy but none in obstetric patients. Aspiration almost always occurred during induction of anaesthesia. Analysis of practice patterns disclosed significant deviations from recommendations. French anaesthetists should voluntarily move through a personal and active process toward an improvement of their practice to reduce the incidence of aspiration.

Anesthesia mortality.

Since the first report in 1846 on the use of anesthesia for a surgical procedure, deaths have occurred with practically every agent and technique used. Those mishaps of which we are aware are probably just a small segment of those that have actually occurred, since presently there is no widely used method for identifying anesthesia-associated deaths. Several sources of information are available, including the United States National Center for Health Statistics and articles in the medical literature. Neither of these encompasses more than a fraction of the total experience; in addition, the population upon which most reports are based and the number of anesthesias involved are usually not available as a denominator in determining the incidence of mishaps and the magnitude of the problem. Extrapolating from data from community anesthesia study committees and from population and operative figures, we can estimate that there are over 5,000 deaths associated with anesthesia in this country each year. This is 3 times as many as are caused by muscular dystrophy and multiple sclerosis, 15 times as many as with sickle cell anemia, 20 times as many as with myasthenia gravis and 40 times as many with poliomyelitis. We thus must recognize that anesthesia is an iatrogenic disease that deserves serious attention as a public health problem.