Propofol-based Total Intravenous Anesthesia Is Associated with Better Survival Than Desflurane Anesthesia in Colon Cancer Surgery.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Previous research has shown different effects of anesthetics on cancer cell growth. Here, the authors investigated the association between type of anesthetic and patient survival after elective colon cancer surgery. METHODS: A retrospective cohort study included patients who received elective colon cancer surgery between January 2005 and December 2014. Patients were grouped according to anesthesia received: propofol or desflurane. After exclusion of those who received combined propofol anesthesia with inhalation anesthesia or epidural anesthesia, survival curves were constructed from the date of surgery to death. After propensity matching, univariable and multivariable Cox regression models were used to compare hazard ratios for death. Subgroup analyses were performed for tumor-node-metastasis staging and postoperative metastasis. RESULTS: A total of 706 patients (307 deaths, 43.5%) with desflurane anesthesia and 657 (88 deaths, 13.4%) with propofol anesthesia were eligible for analysis. After propensity matching, 579 patients remained in each group (189 deaths, 32.6%, in the desflurane group vs. 87, 15.0%, in the propofol group). In the matched analyses, the propofol-treated group had a better survival, irrespective of lower tumor-node-metastasis stage (hazard ratio, 0.22; 95% CI, 0.11 to 0.42; P < 0.001) or higher tumor-node-metastasis stage (hazard ratio, 0.42; 95% CI, 0.32 to 0.55; P < 0.001) and presence of metastases (hazard ratio, 0.67; 95% CI, 0.51 to 0.86; P = 0.002) or absence of metastases (hazard ratio, 0.08; 95% CI, 0.01 to 0.62; P = 0.016). Simple propensity score adjustment produced similar findings. CONCLUSIONS: Propofol anesthesia for colon cancer surgery is associated with better survival irrespective of tumor-node-metastasis stage.

An analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in ophthalmic surgery: a retrospective study.

BACKGROUND: Anesthetic techniques can contribute to reduction of anesthesia-controlled time to improve operating room (OR) efficiency. However, little is known about the difference in anesthesia-controlled time between propofol-based total IV anesthesia (TIVA) and desflurane anesthesia (DES) techniques for ophthalmic surgery under general anesthesia. METHODS: We performed a retrospective analysis using hospital databases to compare the anesthesia-controlled times of ophthalmic surgery patients receiving either TIVA via target-controlled infusion with propofol/fentanyl or desflurane/fentanyl-based anesthesia between January 2010 and December 2011. The various time intervals (surgical time, incision to surgical completion and application of dressings; anesthesia time, start of anesthesia to extubation; extubation time, surgery complete and dressings applied to extubation; time in OR, arrival in the OR to departure from the OR; postanesthetic care unit (PACU) stay time, arrival in the PACU to discharge from the PACU to the general ward; and total surgical suite time, arrival in the OR to discharge from the PACU to the general ward) that comprise a patient's hospital stay and the incidence of postoperative nausea and vomiting were compared between the 2 anesthetic techniques. RESULTS: We included data from 1405 patients, with 595 patients receiving TIVA and 810 receiving DES. The extubation time was faster (TIVA-DES = -1.85 minutes, 99.2% confidence interval [CI], -2.47 to -1.23 minutes) and the PACU stay time was shorter (TIVA-DES = -3.62 minutes, 99.2% CI, -6.97 to -0.10 minutes) in the TIVA group than in the DES group. However, there was no significant difference in total surgical suite time between groups (TIVA-DES = -5.03 minutes, 99.2% CI, -11.75 to 1.69 minutes). We performed the random-effects analyses while stratifying for procedure and showed that the extubation time in the TIVA group was faster by 14% (99.2% CI, 9% to 19%, P < 0.0001) relative to the DES group, and the PACU stay time was faster by 5% (99.2% CI, 1% to 10%, P = 0.002). Significantly fewer patients suffered postoperative nausea and vomiting and required rescue therapy in the TIVA group than in the DES group (11.3% vs 32.2%, risk difference 21.0%, 95% CI, 16.9% to 25.1%, P < 0.001 and 23.9% vs 54.0%, risk difference 30.1%, 95% CI, 18.3% to 42.0%, P = 0.002, respectively). CONCLUSIONS: In our hospital, the use of TIVA reduced the mean time to extubation by at least 9% and PACU stay time by more than 1% when compared with the use of DES anesthesia for ophthalmic surgery.

The effectiveness of benzydamine hydrochloride spraying on the endotracheal tube cuff or oral mucosa for postoperative sore throat.

BACKGROUND: The etiology of postoperative sore throat (POST) is considered to be the result of laryngoscopy, intubation damage, or inflated cuff compression of the tracheal mucosa. In this study, we compared the effectiveness in alleviating POST using different approaches to benzydamine hydrochloride (BH) administration by spraying the endotracheal tube (ET) cuff or the oropharyngeal cavity, or both. METHODS: Three hundred eighty patients were included in this prospective and double-blind study, which was randomized into 4 groups: group A, oropharyngeal cavity spray of BH, and distilled water on the ET cuff; group B, both the oropharyngeal cavity and the ET cuff received BH spray; group C, the ET cuff received BH spray, and the oropharyngeal cavity received distilled water; and group D, distilled water sprayed on both the ET tube and into the oropharyngeal cavity. The patients were examined for sore throat (none, mild, moderate, severe) at 0, 2, 4, and 24 hours postextubation. RESULTS: The incidence of POST was 23.2%, 13.8%, 14.7%, and 40.4% in groups A, B, C, and D, respectively. POST occurred significantly less frequently in groups B and C compared with group D (odds ratio: 0.36; 95% confidence interval: 0.21-0.60; P < 0.05). However, there was no significant difference between groups A and D (odds ratio: 0.62; 95% confidence interval: 0.38-1.01). Moreover, there was no significant interaction between spraying BH over the oropharyngeal cavity and the ET cuff on the incidence of POST (P = 0.088). The severity of POST was significantly more intense in group D compared with groups B and C (P < 0.001). Group B had a significantly higher incidence of local numbness, burning, and/or stinging sensation compared with patients in group D (P < 0.05). CONCLUSIONS: This study indicates that spraying BH on the ET cuff decreases the incidence and severity of POST without increased BH-related adverse effects.

Effect on postoperative sore throat of spraying the endotracheal tube cuff with benzydamine hydrochloride, 10% lidocaine, and 2% lidocaine.

BACKGROUND: Postoperative sore throat (POST) is a common complication after endotracheal intubation. We compared the effectiveness on POST of spraying the endotracheal tube (ETT) cuff with benzydamine hydrochloride, 10% lidocaine, and 2% lidocaine. METHODS: Three hundred seventy-two patients were randomly allocated into 4 groups. The ETT cuffs in each group were sprayed with benzydamine hydrochloride, 10% lidocaine hydrochloride, 2% lidocaine hydrochloride, or normal saline before endotracheal intubation. After insertion, the cuffs were inflated to an airway leak pressure of 20 cm H(2)O. Anesthesia was maintained with propofol. The patients were examined for sore throat (none, mild, moderate, or severe) at 1, 6, 12, and 24 hours after extubation. RESULTS: The highest incidence of POST occurred at 6 hours after extubation in all groups. There was a significantly lower incidence of POST in the benzydamine group than 10% lidocaine, 2% lidocaine, and normal saline groups (P < 0.05) at each observation time point. At 6 hours after extubation, the incidence of POST was significantly lower in the benzydamine group (17.0%) compared with 10% lidocaine (53.7%), 2% lidocaine (37.0%), and normal saline (40.8%) groups (P < 0.05). The benzydamine group had significantly decreased severity of POST compared with the 10% lidocaine, 2% lidocaine, and normal saline groups (P < 0.05) at each observation time point. Compared with the 2% lidocaine and normal saline groups, the 10% lidocaine group had significantly increased severity of POST at 1, 6, and 12 hours after extubation. There were no significant differences among groups in local or systemic side effects. CONCLUSIONS: Spraying benzydamine hydrochloride on the ETT cuff is a simple and effective method to reduce the incidence and severity of POST.

Propofol vs desflurane on the cytokine, matrix metalloproteinase-9, and heme oxygenase-1 response during living donor liver transplantation: A pilot study.

BACKGROUND: We investigated the effects of propofol vs desflurane on ischemia and reperfusion injury (IRI)-induced inflammatory responses, especially in matrix metalloproteinase-9 (MMP-9) downregulation and heme oxygenase-1 (HO-1) upregulation, which may result in different clinical outcomes in liver transplant recipients. METHODS: Fifty liver transplant recipients were randomized to receive propofol-based total intravenous anesthesia (TIVA group, n = 25) or desflurane anesthesia (DES group, n = 25). We then measured the following: perioperative serum cytokine concentrations (interleukin 1 receptor antagonist [IL-1RA], IL-6, IL-8, and IL-10); MMP-9 and HO-1 mRNA expression levels at predefined intervals. Further, postoperative outcomes were compared between the 2 groups. RESULTS: The TIVA group showed a significant HO-1 level increase following the anhepatic phase and a significant MMP-9 reduction after reperfusion, in addition to a significant increase in IL-10 levels after the anhepatic phase and IL-1RA levels after reperfusion. Compared to DES patients, TIVA patients showed a faster return of the international normalized ratio to normal values, lower plasma alanine aminotransferase concentrations 24 hours after transplantation, and fewer patients developing acute lung injury. Moreover, compared with DES patients, TIVA patients showed a significant reduction in serum blood lactate levels. However, there were no differences in postoperative outcomes between the two groups. CONCLUSION: Propofol-based TIVA attenuated inflammatory response (elevated IL-1RA and IL-10 levels), downregulated MMP-9 response, and increased HO-1 expression with improved recovery of graft function and better microcirculation compared with desflurane anesthesia in liver transplant recipients.

The Relationship Between Postoperative Pneumonia and Endotracheal Suctioning Under General Anesthesia in Ophthalmic Surgery: A Retrospective Study.

OBJECTIVE: Postoperative pneumonia is the third most common postoperative complication. It may result from aspiration of secretions accumulating in the subglottic space during general anesthesia (GA). However, the relationship between endotracheal suctioning (ETS) during extubation from GA emergence and postoperative pneumonia has not been well investigated. Therefore, the aim of this study was to investigate the effectiveness of ETS during extubation in prevention of postoperative pneumonia in ophthalmic surgery under GA in our medical center from 2011 through 2015. METHODS: Three thousand, seven hundred and ninety-four patients receiving ophthalmic surgery under GA were included and divided into two groups by the anesthesiologists. The first group underwent the conventional ETS during extubation, while the other group was extubated without ETS. The incidences of postoperative pneumonia were compared between the two groups to find the correlation between ETS during extubation and postoperative pneumonia. In addition, other complication such as postoperative hemorrhage was also recorded. RESULTS: Of the 3,794 patients undergoing ophthalmic surgery under GA, 2,187 (58%) patients underwent extubation with ETS, whilst 1,607 (42%) patients were extubated without ETS. The incidence rates of postoperative pneumonia with or without ETS during extubation were both 0%. Besides, the incidence rates of postoperative hemorrhage were also both 0% in two groups. CONCLUSIONS: Extubation from GA without ETS seemed not to increase the risk of postoperative pneumonia. Thus, no routine ETS during extubation seemed not to be a risk factor for postoperative pneumonia under GA in ophthalmic surgery.

Analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in functional endoscopic sinus surgery.

Anesthesia technique may contribute to the improvement of operation room (OR) efficiency by reducing anesthesia-controlled time. We compared the difference between propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia (DES) for functional endoscopic sinus surgery (FESS) undergoing general anesthesiaWe performed a retrospective study using data collected in our hospital to compare the anesthesia-controlled time of FESS using either TIVA via target-controlled infusion with propofol/fentanyl or DES/fentanyl-based anesthesia between January 2010 and December 2011. The various time intervals (surgical time, anesthesia time, extubation time, total OR stay time, post anesthesia care unit [PACU] stay time) and the percentage of prolonged extubation were compared between the 2 anesthetic techniques.We included data from 717 patients, with 305 patients receiving TIVA and 412 patients receiving DES. An emergence time >15 minutes is defined as prolonged extubation. The extubation time was faster (8.8 [3.5] vs. 9.6 [4.0] minutes; P = .03), and the percentage of prolonged extubation was lower (7.5% vs. 13.6%, risk difference 6.1%, P < .001) in the TIVA group than in the DES group. However, there was no significant difference between ACT, total OR stay time, and PACU stay time.In our hospital, propofol-based TIVA by target-controlled infusion provide faster emergence and lower chance of prolonged extubation compared with DES anesthesia in FESS. However, the reduction in extubation time may not improve OR efficiency.

Epidural clonidine for postoperative pain after total knee arthroplasty: a dose-response study.

BACKGROUND: Combinations of epidural clonidine, local anesthetics, and opioids have improved postoperative analgesia after total knee arthroplasty. In this study we sought to determine the optimal epidural bolus dose of clonidine, which provides the best analgesia and fewest side effects. METHODS: Eighty ASA I-III patients, who underwent total knee arthroplasty were randomly assigned to one of four groups of 20 patients each. Identical epidural anesthesia procedures were used for all groups. After surgery, groups C0, C1, C2, and C4 received patient-controlled epidural analgesia (PCEA) with clonidine (0, 1.0, 2.0, or 4.0 mug/mL, respectively) and morphine (0.1 mg/mL) in 0.2% ropivacaine. The analgesia effect was estimated by PCEA consumption volume and visual analog pain scale at rest and with movement at 1, 2, 4, 12, 24, 48, and 72 h after surgery. Systolic blood pressure, heart rate, sedation, and sensory and motor blockade were also recorded for 72 h after surgery. RESULTS: The PCEA consumption volume for groups C0, C1, C2, and C4 were 71.8 +/- 19.5 mL, 49.6 +/- 12.3 mL, 48.1 +/- 9.3 mL, and 39.4 +/- 9.0 mL, respectively. The clonidine groups experienced less postoperative pain (P = 0.002). In the C4 group, four patients had prolonged sensory blockade and one patient had both severe sedation and prolonged sensory motor blockade. No significant statistical difference in analgesic consumption (P = 0.78) and pain intensity (P = 0.66) between groups C1 and C2 were noted. CONCLUSIONS: The optimal amount of epidural clonidine in a solution of morphine and ropivacaine for postoperative pain management is 1.0 microg/mL.

Faster extubation time with more stable hemodynamics during extubation and shorter total surgical suite time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in lengthy lumbar spine surgery.

OBJECT Anesthesia techniques can contribute to the reduction of anesthesia-controlled time and may therefore improve operating room efficiency. However, little is known about the difference in anesthesia-controlled time between propofol-based total intravenous anesthesia (TIVA) and desflurane (DES) anesthesia techniques for prolonged lumbar spine surgery under general anesthesia. METHODS A retrospective analysis was conducted using hospital databases to compare the anesthesia-controlled time of lengthy (surgical time > 180 minutes) lumbar spine surgery in patients receiving either TIVA via target-controlled infusion (TCI) with propofol/fentanyl or DES/fentanyl-based anesthesia, between January 2009 and December 2011. A variety of time intervals (surgical time, anesthesia time, extubation time, time in the operating room, postanesthesia care unit [PACU] length of stay, and total surgical suite time) comprising perioperative hemodynamic variables were compared between the 2 anesthesia techniques. RESULTS Data from 581 patients were included in the analysis; 307 patients received TIVA and 274 received DES anesthesia. The extubation time was faster (12.4 ± 5.3 vs 7.0 ± 4.5 minutes, p < 0.001), and the time in operating room and total surgical suite time was shorter in the TIVA group than in the DES group (326.5 ± 57.2 vs 338.4 ± 69.4 minutes, p = 0.025; and 402.6 ± 60.2 vs 414.4 ± 71.7 minutes, p = 0.033, respectively). However, there was no statistically significant difference in PACU length of stay between the groups. Heart rate and mean arterial blood pressure were more stable during extubation in the TIVA group than in the DES group. CONCLUSIONS Utilization of TIVA reduced the mean time to extubation and total surgical suite time by 5.4 minutes and 11.8 minutes, respectively, and produced more stable hemodynamics during extubation compared with the use of DES anesthesia in lengthy lumbar spine surgery.

Confounding factors to predict the awakening effect-site concentration of propofol in target-controlled infusion based on propofol and fentanyl anesthesia.

We conducted a large retrospective study to investigate the confounding factors that predict Ce ROC under propofol-based TIVA with TCI. We recorded sex, age, height, weight, Ce LOC, Ce ROC, total propofol and fentanyl consumption dose, and anesthetic time. Simple linear regression models were used to identify potential predictors of Ce ROC, and multiple linear regression models were used to identify the confounding predictors of Ce ROC. We found that Ce ROC correlated with age, sex, Ce LOC, and both total fentanyl and propofol consumption dose. The prediction formula was: Ce ROC = 0.87 - 0.06 × age + 0.18 × Ce LOC + 0.04 (if fentanyl consumption > 150 µg; if not, ignore this value) + 0.07 × (1 or 2, according to the total propofol consumption dose, 1 for a propofol amount 1000-2000 mg and 2 for a propofol amount > 2000 mg). We simplified the formula further as Ce ROC = 0.87 - 0.06 × age + 0.18 × Ce LOC. In conclusion, Ce ROC can be predicted under TCI with propofol- and fentanyl-based TIVA. The confounding factors that predicted propofol Ce ROC are age, sex, Ce LOC, and total consumption dose of propofol and fentanyl.

Hemodynamic and biochemical changes in liver transplantation: A retrospective comparison of desflurane and total intravenous anesthesia by target-controlled infusion under auditory evoked potential guide.

OBJECTIVES: Propofol-based total intravenous anesthesia (TIVA) has been used successfully for liver transplantation (LT) in recent years. However, there are few discourses in the literature which focus on the merits and weakness in perioperative management, biochemical changes, and postoperative recovery between TIVA and desflurane anesthesia (DES). METHODS: We retrospectively compared the circumstances of liver transplantation recipients who had the surgery carried out under propofol-based TIVA or DES in the period from September 2007 to August 2010. Preoperative characteristics, date of intraoperative management, hemodynamic profiles, concentration of anesthetics, biochemical changes, and circumstances of postoperative recovery were retrieved from the hospital database for analysis. RESULTS: We included 111 patients who received the surgery under either TIVA (n = 66) or DES (n = 45). Patient demographics, baseline laboratory data, operation time, and fluid management did not differ between the two groups. In comparison with the DES group, fewer patients had to be administered norepinephrine (21.2% vs. 42.2%; p = 0.020) in the TIVA group; moreover, the total dosage of norepinephrine was lower (0.003 ± 0.005 mg vs. 0.006 ± 0.008 mg; p = 0.012) in the TIVA group during liver reperfusion phase. Blood lactate level was higher in the DES group than in the TIVA group after the anhepatic phase. TIVA patients woke up faster than those in the DES group (54.0 ± 33.4 minutes vs. 95.0 ± 78.3 minutes; p = 0.034). CONCLUSION: Our results suggest that propofol-based TIVA may provide better hemodynamics and microcirculation during the anhepatic phase in liver transplantation.

Comparison of A-line autoregressive index and observer assessment of alertness/sedation scale for monitored anesthesia care with target-controlled infusion of propofol in patients undergoing percutaneous vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty (PV) with monitored anesthesia care (MAC) is a growing trend. Without adequate sedation, patient movement can affect and even interrupt the procedure during MAC. The aim of this study was to compare the performance of the auditory-evoked potential (AEP) index and the Observer Assessment of Alertness/Sedation (OAA/S) scale as indicators of depth of sedation in patients undergoing PV. METHODS: Two hundred and twenty patients in ASA II to III, aged 43 to 92 years, undergoing elective PV with MAC, were randomly allocated to the AEP or the OAA/S group (n = 110 each). Initially, all patients received 1 µg/kg of fentanyl and 0.02 mg/kg of midazolam intravenously and sedation with a target-controlled infusion (TCI) of propofol at a target concentration of 1.2 µg/mL. The concentration for the propofol TCI was adjusted in 0.2 µg/mL increments or decrements according to the A-Line autoregressive index (AAI) or the OAA/S scale. A blinded study nurse recorded the measured parameters. RESULTS: Some parameters were significantly different in the AEP group compared with the OAA/S group: lower AAI, lower OAA/S score, lower respiratory rates, and higher end-tidal carbon dioxide pressure were noted from local anesthetic infiltration to bone cement implantation, fewer patients whose movements affected the procedure (10 vs. 36, respectively, P < 0.001), and more adjustments of TCI (twice vs. once, respectively, P < 0.006). The surgeons' satisfaction was greater for the AEP group than for the OAA/S group. CONCLUSIONS: TCI propofol with AEP monitoring can provide less patient movement, better sedation, and higher surgeon satisfaction in patients during prone-position PV procedures than can TCI propofol with OAA/S monitoring.

Intrapleural misplacement of a thoracic epidural catheter in an anesthetized patient.

Thoracic epidural analgesia provides adequate postoperative pain relief and favorable outcomes in major operations. However, a small number of devastating complications have been reported. Here we present a case of asymptomatic but potentially life-threatening intrapleural insertion of a thoracic epidural catheter intended for postoperative analgesia. A 39-year-old male diagnosed with esophageal carcinoma was scheduled for esophageal reconstruction. After induction of general anesthesia, a thoracic epidural catheter was inserted with a paramedian approach at the T8-9 interspace, using loss of resistance to ensure correct placement. The administration of a test dose of 2% lidocaine with epinephrine was unremarkable. After right thoracotomy, the epidural catheter was found in the right pleural cavity and was instantly removed. The patient underwent the operation smoothly and was discharged 10 days later without any sequelae. We recommend practitioners estimate the depth from the skin to the epidural space by computed tomography scan before operation and perform the placement of thoracic epidural catheter while the patient is awake to avoid accidental intrapleural misplacement.

Repeated lumbar sympathetic blockade with lidocaine and clonidine attenuates pain in complex regional pain syndrome type 1 patients--a report of two cases.

Repeated lumbar sympathetic blockade (LSB) with local anesthetics is generally used in complex regional pain syndrome (CRPS) of the lower extremities if the initial block has been successful. However, the symptoms of CRPS may inevitably recur in spite of repeated LSB. Clonidine, an alpha2-adrenoceptor agonist, has both anesthetic and analgesic sparing effects, and when added to local anesthetics may enhance peripheral and central neural block due to its local or central analgesic effects. It is reasonable that clonidine has been used in chronic pain conditions such as neuropathic and sympathetically maintained pain. Here we report two cases of CRPS type 1 who got excellent analgesia and alleviation of clinical symptoms after receiving an LSB with lidocaine and clonidine.