Adapting general anaesthesia for a patient with class III obesity and obstructive sleep apnoea undergoing day case laparoscopic cholecystectomy: A case report.

This report describes the anaesthesia provided for a class III obese patient with obstructive sleep apnoea, undergoing an elective laparoscopic cholecystectomy. Several adaptations were required to provide safe anaesthesia. A McGrath video laryngoscopy was utilised for intubation. The patient was positioned in the ramped position, thereby increasing time to desaturation on induction of anaesthesia. Pressure controlled ventilation - volume guaranteed mode was selected for ventilation to provide consistent tidal volumes. An increased level of positive end-expiratory pressure was utilised to minimise atelectasis. Drug doses were carefully considered and calculated with the aid of The Society for Obesity and Bariatric Anaesthesia dose calculator. The airway management adaptations provided an unobstructed view for intubation. Peak airway pressures during surgery remained within safe limits and no atelectasis was evident postoperatively. Pain was kept under control and desaturation was avoided during postanaesthetic care. The patient was discharged home later that evening.

A survey on the use of total intravenous anaesthesia in small animals by veterinary anaesthesiologists.

OBJECTIVE: To describe the use of total intravenous anaesthesia (TIVA) in dogs and cats by veterinary anaesthesiologists. STUDY DESIGN: A cross-sectional online, voluntary, anonymous survey. POPULATION: Data from 153 answered questionnaires. METHODS: An anonymous questionnaire was sent via e-mail to diplomates, residents and residency-trained individuals from the American and European Colleges of Veterinary An(a)esthesia and Analgesia, to gather information on the use, perceived advantages, reasons for the use or not of TIVA and attitudes towards this technique in dogs and cats. Descriptive statistics and logistic regression analysis to detect significant associations were performed. The effect size was estimated using the odds ratio (OR) and 95% confidence interval (CI). A significance level of p < 0.05 was used. RESULTS: We obtained 153/703 responses (66% diplomates, 34% residents; overall response rate of 21.7%). Although 99% and 94% of respondents used TIVA in dogs and cats, respectively, only 14% used it frequently (several times a week) in dogs, and < 1% in cats. Most respondents used propofol (97%, dogs) and alfaxalone (85%, cats), mostly combined with opioids. Reasons for not using TIVA more frequently included prolonged recovery (49%, dogs; 61%, cats), higher cost (46%, dogs) and concerns about drug accumulation (44%, cats). Frequent TIVA use was driven by clinical indications (100%) and greater haemodynamic stability (87%). A higher proportion of respondents using TIVA frequently reported the high stability of the anaesthetic plane (20%; OR = 5.0; 95% CI: 1.4-17.8; p = 0.013) and disagreed with using TIVA only when a specific clinical indication existed (OR = 3.3; 95% CI: 1.4-10.0; p = 0.013). CONCLUSIONS AND CLINICAL RELEVANCE: Although occasional, TIVA use is reported among veterinary anaesthesiologists. Clinical indications for TIVA are the most likely reason for its use, whereas factors such as a prolonged recovery or higher cost might limit its use.

Drugs used for pain management in gastrointestinal surgery and their implications.

Pain is the predominant symptom troubling patients. Pain management is one of the most important aspects in the management of surgical patients leading to early recovery from surgical procedures or in patients with chronic diseases or malignancy. Various groups of drugs are used for dealing with this; however, they have their own implications in the form of adverse effects and dependence. In this article, we review the concerns of different pain-relieving medicines used postoperatively in gastrointestinal surgery and for malignant and chronic diseases.

Comparative Efficacy of Intraoperative Patient State Index vs. Bi-Spectral Index in Patients Undergoing Elective Spine Surgery with Neuromonitoring Under General Anaesthesia: A Randomized Controlled Trial.

Objective: Various electroencephalogram-based monitors have been introduced to objectively quantify anaesthesia depth. However, limited data are available on their comparative clinical efficacy in various surgical procedures. Therefore, we planned this study to compare the relative efficacy of patient state index (PSI) vs. Bi-spectral index (BIS) assessment in patients undergoing elective spine surgery under general anaesthesia. Methods: This prospective, parallel-group, single-center study included patients undergoing major spine surgery with neuromonitoring. Patients were randomized into two groups, i.e., group B (undergoing surgery under BIS monitoring) and group P (undergoing surgery under PSI monitoring). The primary objective was to compare the time to eye opening after stopping anaesthetic drug infusions. Results: The mean propofol dose required for induction in group B was 130.45±26.579, whereas that in group P, it was 139.28±17.86 (P value 0.085). The maintenance doses of propofol and fentanyl required for surgery were also comparable between the groups. Time to eye opening was 12.2±4.973 in group B and 12.93±4.19 in group P, with a P value of 0.2664 (U-statistic-684.50). Conclusion: The intraoperative PSI and BIS had similar clinical efficacy in terms of the dose of propofol required for induction, time of induction, maintenance dose of propofol and fentanyl, time of eye opening, and recovery profile in patients undergoing elective spine surgery under neuromonitoring.

Anaesthesia considerations for assisted reproductive technology: a focused review.

The global burden of infertility is significant and the evidence suggests it is increasing in prevalence worldwide. Assisted reproductive technologies (ARTs) are fertility related treatments used to achieve pregnancy which involve the manipulation of both oocytes and sperm. The specialty is rapidly growing and anaesthesia may be required for several stages in the ART cycle. Anaesthesiologists should appreciate the processes involved and how anaesthesia care can influence safe and effective treatment outcomes. In this review article we explain the key steps of the ART cycle and the role of anaesthesiologists in this process. We also highlight key patient considerations, the implications of remote site anaesthesia and the safety concerns with provision of sedation by non-anaesthesiologists. Finally we outline a typical anaesthetic technique used in our institution for transvaginal oocyte retrieval.

Effects of inhalation versus total intravenous anaesthesia on long-term mortality in older patients after noncardiac surgery: a retrospective observational study.

BACKGROUND: Whether the anaesthetic agent used influences postoperative mortality in older patients remains unclear. We evaluated the effect of total intravenous anaesthesia (TIVA) vs inhalation anaesthesia on long-term mortality in older patients after noncardiac surgery. METHODS: We retrospectively analysed 45,879 patients aged ≥60 yr who underwent noncardiac surgery under general anaesthesia (for ≥2 h) between January 2011 and June 2019. They were divided into two groups according to the type of maintenance anaesthetic. The primary outcome was all-cause mortality within 1 yr after surgery. Secondary outcomes included postoperative complications (postoperative pulmonary complications, perioperative adverse cardiovascular events, and acute kidney injury), and 3-yr and 5-yr mortality after surgery. The stabilised inverse probability of treatment weighting method was used to adjust for potential confounders. RESULTS: Among 45,879 patients, 7273 (15.9%) patients received TIVA and 38,606 (84.1%) patients received inhalation anaesthesia. After adjustment with inverse probability of treatment weighting, there was no association between the type of anaesthetic agent and 1-yr mortality (hazard ratio=0.95; 95% confidence interval [CI] 0.84-1.08). Results for 3-yr and 5-yr mortality were similar. However, inhalation anaesthesia was associated with increased risk of postoperative complications (odds ratio [OR]=1.30; 95% CI 1.22-1.37 for postoperative pulmonary complications, OR=1.34; 95% CI 1.22-1.48 for perioperative adverse cardiovascular events, and OR=2.19; 95% CI 1.88-2.57 for acute kidney injury). In the subgroup analysis, the choice of anaesthetic agent showed differential effects on 1-yr mortality for female patients and emergency surgery. CONCLUSION: The choice of anaesthetic agent during the intraoperative period was not associated with 1-yr mortality in older patients undergoing noncardiac surgery. CLINICAL TRIAL REGISTRATION: Clinical Research Information Service of the Republic of Korea (KCT 0006363).

Predictive pharmacodynamic performance of the Eleveld pharmacokinetic-pharmacodynamic model for propofol: comparison of predicted and measured bispectral index.

BACKGROUND: The Eleveld pharmacokinetic-pharmacodynamic model for propofol predicts bispectral index (BIS) processed electroencephalogram values from estimated effect-site concentrations. We investigated agreement between measured and predicted BIS values during total intravenous anaesthesia (TIVA). METHODS: Forty participants undergoing lower limb surgery received TIVA using remifentanil target-controlled infusions and propofol by manually controlled, target-guided infusions based upon the Eleveld model and directed by two pharmacokinetic computer simulation applications: PKPD Tools and StelSim. We evaluated the predictive performance of the Eleveld model by calculating median prediction errors (BIS units) and by Bland-Altman analyses. We also performed |Bland-Altman analysis of supplementary data provided by the authors of the Eleveld model. RESULTS: Whereas median prediction errors were small (MDPE -1.9, MDAPE 10), the ranges were wide (-18.5 to 24.3 and 1.7 to 24.3). The proportion of MDAPE >10 BIS units was 47.8%. Bland-Altman analysis showed a small mean bias (-0.52 BIS units) with wide limits of agreement (-27.7 to 26.2). Each participant's limits of agreement did not meet the requirements for declaring interchangeability between the two measurements. The measurement differences depended on the BIS values, as indicated by the positive slopes of the differences vs BIS values. Bland-Altman analysis of the Eleveld model supplementary data revealed similar results. CONCLUSION: BIS predictions by the Eleveld model should be interpreted with caution. In spite of the acceptable MDPE and MDAPE, there are unacceptable degrees of both within-subject and between-subject variation during propofol target-controlled infusions. This limits the use of adjusting targeted concentrations to achieve desired simulated BIS values with confidence.

Effect of volatile versus propofol anaesthesia on major complications and mortality after cardiac surgery: a multicentre randomised trial.

BACKGROUND: The comparative effectiveness of volatile anaesthesia and total intravenous anaesthesia (TIVA) in terms of patient outcomes after cardiac surgery remains a topic of debate. METHODS: Multicentre randomised trial in 16 tertiary hospitals in China. Adult patients undergoing elective cardiac surgery were randomised in a 1:1 ratio to receive volatile anaesthesia (sevoflurane or desflurane) or propofol-based TIVA. The primary outcome was a composite of predefined major complications during hospitalisation and mortality 30 days after surgery. RESULTS: Of the 3123 randomised patients, 3083 (98.7%; mean age 55 yr; 1419 [46.0%] women) were included in the modified intention-to-treat analysis. The composite primary outcome was met by a similar number of patients in both groups (volatile group: 517 of 1531 (33.8%) patients vs TIVA group: 515 of 1552 (33.2%) patients; relative risk 1.02 [0.92-1.12]; P=0.76; adjusted odds ratio 1.05 [0.90-1.22]; P=0.57). Secondary outcomes including 6-month and 1-yr mortality, duration of mechanical ventilation, length of ICU and hospital stay, and healthcare costs, were also similar for the two groups. CONCLUSIONS: Among adults undergoing cardiac surgery, we found no difference in the clinical effectiveness of volatile anaesthesia and propofol-based TIVA. CLINICAL TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR-IOR-17013578).

Is target-controlled infusion better than manual controlled infusion during TIVA for elective neurosurgery? Results of a single-centre pilot study.

INTRODUCTION: Maintaining optimal systemic circulatory parameters is essential to ensure adequate cerebral perfusion (CPP) during neurosurgery, especially when autoregulation is impaired. AIM OF STUDY: To compare two types of total intravenous anaesthesia i.e. target controlled infusion (TCI) and manually controlled infusion (MCI) with propofol and remifentanil in terms of their control of cardiovascular parameters during neurosurgical resection of intracranial pathology. MATERIAL AND METHODS: Patients with supratentorial intracranial pathology were selected for the study. Patients in ASA grades III and IV and those with diseases of the circulatory system were excluded. Patients were randomly divided into two equal groups according to the method of general anaesthesia used i.e. TCI or MCI. During the neurosurgery, the values of mean arterial pressure (MAP), heart rate (HR), bispectral index (BIS) and central venous pressure were monitored and recorded at the designated 14 relevant (i.e. critical from the anaesthetist's and neurosurgeon's points of view) measurement points. RESULTS: Fifty patients (25 TCI and 25 MCI) were enrolled in the study. The groups did not differ with respect to sex, age and BMI, operation time or volume of removed lesions. TCI-anaesthetised patients had better MAP stability at the respective time points. CONCLUSIONS: Due to the greater stability of MAP, which has a direct effect on CPP, TCI appears to be the method of choice in anaesthesia for intracranial surgery.

Comparison of anaesthesia strategies on postoperative nausea and vomiting in laparoscopic sleeve gastrectomy: a randomised controlled trial.

BACKGROUND: Intra-operative anaesthesia management should be optimised to reduce the occurrence of postoperative nausea and vomiting in high-risk patients; however, a single intervention may not effectively reduce postoperative nausea and vomiting in such patients. This study assessed the effect of an optimised anaesthetic protocol versus a conventional one on postoperative nausea and vomiting in patients who underwent laparoscopic sleeve gastrectomy. METHODS: A single-centre randomised trial was conducted at Peking University Shenzhen Hospital from June 2021 to December 2022. Among 168 patients who underwent laparoscopic sleeve gastrectomy, 116 qualified, and 103 completed the study with available data. Patients were categorized into the conventional group (received sevoflurane and standard fluids) and the optimised group (underwent propofol-based anaesthesia and was administered goal-directed fluids). The primary endpoints were postoperative nausea and vomiting incidence and severity within 24 h. RESULTS: Postoperative nausea and vomiting assessment at 0-3 h post-surgery revealed no significant differences between groups. However, at 3-24 h, the optimised anaesthetic protocol group showed lower postoperative nausea and vomiting incidence and severity than those of the conventional group (P = 0.005). In the conventional group, 20 (37.04%) patients experienced moderate-to-severe postoperative nausea and vomiting, compared to six (12.25%) patients in the optimised group (odds ratio = 0.237; 95% CI = 0.086, 0.656; P = 0.006). No significant differences were noted in antiemetic treatment, moderate-to-severe pain incidence, anaesthesia recovery, post-anaesthetic care unit stay, or postoperative duration between the groups. While the total intra-operative infusion volumes were comparable, the optimised group had a significantly higher colloidal infusion volume (500 mL vs. 0 mL, P = 0.014) than that of the conventional group. CONCLUSIONS: The incidence and severity of postoperative nausea and vomiting 3-24 h postoperatively in patients who underwent laparoscopic sleeve gastrectomy were significantly lower with propofol-based total intravenous anaesthesia and goal-directed fluid therapy than with sevoflurane anaesthesia and traditional fluid management. Total intravenous anaesthesia is an effective multimodal antiemetic strategy for bariatric surgery. TRIAL REGISTRATION: This trial was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC- 2,100,046,534, registration date: 21 May 2021).

Comparison of Complications between Total Intravenous Anaesthesia and Combined Intravenous and Inhalation Anaesthesia after Renal Biopsy in Children.

OBJECTIVE: The objective of this study was to examine the influence of total intravenous anaesthesia (TIVA) compared to combined intravenous and inhalation anaesthesia (CIIA) in paediatric patients undergoing renal biopsy. METHODS: A total of 86 children with nephrotic syndrome, acute glomerulonephritis, chronic glomerulonephritis, IgG nephropathy, systemic lupus erythematosus and purpura nephritis were selected from January 2018 to January 2023 in our hospital. All children were divided into the total intravenous anaesthesia group and intravenous inhalational anaesthesia group according to the anaesthesia method. The experimental group comprised 46 children with renal diseases who underwent static aspiration compound anaesthesia during renal biopsy at our hospital from January 2018 to January 2023. Conversely, the control group included 40 children with renal diseases who underwent total intravenous anaesthesia during renal biopsy at the hospital within the same period. Hemodynamic parameters, such as mean arterial pressure (MAP), heart rate (HR), and oxygen saturation (SPO2), were assessed at four different time points: Before anesthesia induction (T0), during anesthesia induction (T1), after anesthesia induction (T2), and at the conclusion of the surgery (T3). Puncture success rate, time to renal puncture, time to get out of bed, postoperative recovery from anaesthesia (including time to postoperative awakening and time to return to spontaneous respiration) and incidence of adverse anaesthetic reactions were also included. RESULTS: We observed notable variations in HR and MAP at T2 and T3, as well as SPO2 levels, duration of awakening from anaesthesia and time taken to resume spontaneous respiration between the two groups at T2 (p < 0.05). No statistically significant variances were detected between the two groups concerning adverse reactions to anaesthesia, puncture success rate, duration to renal puncture and time to mobilisation from bed (p > 0.05). CONCLUSIONS: In conclusion, compared with the total intravenous anaesthesia, the implementation of the sedation-aspiration-combined anaesthesia in renal biopsy in children with renal disease features less haemodynamic fluctuation, better postoperative anaesthesia recovery and does not increase the incidence of adverse reactions.

Mortality and morbidity after total intravenous anaesthesia versus inhalational anaesthesia: a systematic review and meta-analysis.

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).

Effect of different anaesthetic techniques on the prognosis of patients with colorectal cancer after resection: a systematic review and meta-analysis.

Background: The effect of total intravenous anaesthesia (TIVA) and inhalation anaesthesia (IA) on the prognosis of patients with colorectal cancer after resection is controversial. This study aimed to explore the effects of different anaesthesia methods on the postoperative prognosis of colorectal cancer. Methods: PubMed, Embase and Cochrane Library databases were searched for relevant literature from each database's inception until 18 November 2023. The literature topic was to compare the effects of TIVA and IA on the prognosis of patients undergoing colorectal cancer resection. Results: Six studies were selected for meta-analysis. The studies involved 111043 patients, with a trial size of 1001-88184 people. A statistically significant difference was observed in the overall survival (OS) between colorectal cancer patients administered TIVA and IA (hazard ratio [HR], 0.83; 95% confidence interval [CI], 0.70-0.99), but none in recurrence-free survival (RFS) (HR, 0.99; 95% CI, 0.90-1.08). In the subgroup analysis of OS, no statistically significant difference was observed between colorectal cancer patients administered TIVA and IA in Asia (HR, 0.77; 95% CI, 0.57-1.05), and not in Europe (HR, 0.99; 95% CI, 0.93-1.06). Regarding tumour location, no significant association was found between TIVA and IA in the colon, rectum and colorectum ((HR, 0.70; 95% CI, 0.38-1.28), (HR, 0.95; 95% CI, 0.83-1.08) and (HR, 0.99; 95% CI, 0.93-1.06), respectively). Conclusion: OS differed significantly between patients administered TIVA and IA when undergoing colorectal cancer resection, but no difference was observed in RFS. The prognostic effects of TIVA and IA differed. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023453185, identifier CRD42023453185.

Total intravenous anaesthesia with propofol and remifentanil is associated with reduction in operative time in surgery for glioblastoma when compared with inhalational anaesthesia with sevoflurane.

BACKGROUND: Total intravenous anaesthesia (TIVA) is emerging as a preferred neuroanaesthetic agent compared with inhalational anaesthetic (IA) agents. We asked if TIVA with propofol and remifentanil was associated with shorter operative times compared to IA using sevoflurane in brain tumour surgery under GA. METHODS: We performed a retrospective analysis of all patients undergoing surgery for glioblastoma (GBM). We assessed choice of GA agent (TIVA or IA) with total time patient was under GA (anaesthetic time), operative time and time taken to recover fully from GA (recovery time). RESULTS: Over a two year period 263 patients underwent surgery under GA for their GBM including 188 craniotomy operations, 63 burr hole biopsy procedures and 12 open biopsy procedures. Of these, 79 operations took place under TIVA and 184 operations under IA. TIVA was associated with significantly reduced mean operative time including time taken to wake up in theatre (104 min with TIVA, 129 min with IA; p = 0.02). TIVA was also associated with trends toward shorter mean recovery time (118 min, versus 135 min with IA; p = 0.08) and shorter mean anaesthetic time (163 min, versus 181 min with IA; p = 0.07). There was no difference between TIVA and IA groups as regards duration of inpatient stay, readmission rates, complications or survival. CONCLUSIONS: TIVA with propofol and remifentanil may reduce anaesthetic, operative and recovery times in patients undergoing surgery for their GBM. These findings may be attributable to favourable effects on intracranial pressure and cerebral perfusion, as well as rapid recovery from GA. In addition to clinical advantages, there may be financial and logistical benefits.

Anaesthetic efficacy and postinduction hypotension with remimazolam compared with propofol: a multicentre randomised controlled trial.

Remimazolam, a short-acting benzodiazepine, may be used for induction and maintenance of total intravenous anaesthesia, but its role in the management of patients with multiple comorbidities remains unclear. In this phase 3 randomised controlled trial, we compared the anaesthetic efficacy and the incidence of postinduction hypotension during total intravenous anaesthesia with remimazolam vs. propofol. A total of 365 patients (ASA physical status 3 or 4) scheduled for elective surgery were assigned randomly to receive total intravenous anaesthesia with remimazolam (n = 270) or propofol (n = 95). Primary outcome was anaesthetic effect, quantified as the percentage of time with Narcotrend® Index values ≤ 60, during surgery (skin incision to last skin suture), with a non-inferiority margin of -10%. Secondary outcome was the incidence of postinduction hypotensive events. Mean (SD) percentage of time with Narcotrend Index values ≤ 60 during surgery across all patients receiving remimazolam (93% (20.7)) was non-inferior to propofol (99% (4.2)), mean difference (97.5%CI) -6.28% (-8.89-infinite); p = 0.003. Mean (SD) number of postinduction hypotension events was 62 (38.1) and 71 (41.1) for patients allocated to the remimazolam and propofol groups, respectively; p = 0.015. Noradrenaline administration events (requirement for a bolus and/or infusion) were also lower in patients allocated to remimazolam compared with propofol (14 (13.5) vs. 20 (14.6), respectively; p < 0.001). In conclusion, in patients who were ASA physical status 3 or 4, the anaesthetic effect of remimazolam was non-inferior to propofol.

Environmental and economic impact of sustainable anaesthesia interventions: a single-centre retrospective observational study.

BACKGROUND: Anaesthesia contributes substantially to the environmental impact of healthcare. To reduce the ecological footprint of anaesthesia, a set of sustainability interventions was implemented in the University Hospital Zurich, Switzerland. This study evaluates the environmental and economic implications of these interventions. METHODS: This was a single-centre retrospective observational study. We analysed the environmental impact and financial implications of changes in sevoflurane, desflurane, propofol, and plastic consumption over 2 yr (April 2021 to March 2023). The study included pre-implementation, implementation, and post-implementation phases. RESULTS: After implementation of sustainability measures, desflurane use was eliminated, there was a decrease in the consumption of sevoflurane from a median (inter-quartile range) of 25 (14-39) ml per case to 11 (6-22) ml per case (P<0.0001). Propofol consumption increased from 250 (150-721) mg per case to 743 (370-1284) mg per case (P<0.0001). Use of plastics changed: in the first quarter analysed, two or more infusion syringes were used in 62% of cases, compared with 74% of cases in the last quarter (P<0.0001). Two or more infusion lines were used in 58% of cases in the first quarter analysed, compared with 68% of cases in the last quarter (P<0.0001). This resulted in an 81% reduction in overall environmental impact from 3 (0-7) to 1 (0-3) CO2 equivalents in kg per case (P<0.0001). The costs during the final study phase were 11% lower compared with those in the initial phase: from 25 (13-41) to 21 (14-31) CHF (Swiss francs) per case (P<0.0001). CONCLUSIONS: Implementing sustainable anaesthesia interventions can significantly reduce the environmental impact and cost of anaesthesia.

On the horns of a dilemma: choosing total intravenous anaesthesia or volatile anaesthesia for cancer surgery, an enduring controversy.

Two methods for administering general anaesthesia are widely used: propofol-based total intravenous anaesthesia (propofol-TIVA) and inhalation volatile agent-based anaesthesia. Both modalities, which have been standards of care for several decades, boast a robust safety profile. Nevertheless, the potential differential effects of these anaesthetic techniques on immediate, intermediate, and extended postoperative outcomes remain a subject of inquiry. We discuss a recently published longitudinal analysis stemming from a multicentre randomised controlled trial comparing sevoflurane-based inhalation anaesthesia with propofol-TIVA in older patients with cancer, which showed a reduced incidence of emergence and postoperative delirium, comparable postoperative complication rates within 30 days after surgery, and comparable long-term survival rates. We undertake an assessment of the trial's methodological strengths and limitations, contextualise its results within the broader scientific evidence, and explore avenues for resolving the extant controversies in anaesthetic choice for cancer surgery. We aim to pave the way for the incorporation of precision medicine paradigms into the evolving landscape of perioperative care for patients with cancer.