Sevoflurane-based Anaesthesia Research Articles

Efficiency of CONTRAfluran™ in reducing sevoflurane pollution from maintenance anaesthesia in minimal flow end-tidal control mode for laparoscopic surgery: Efficiency of CONTRAfluran™.

Recommendations exist that aim to mitigate the substantial ecological impact of anaesthesia. One option is to use anaesthetic gas capturing technology at anaesthesia workstation exhausts to harvest and recycle volatile agents. However, the efficiency of such technology is mainly unverified in vivo. The efficiency of CONTRAfluran™ in capturing sevoflurane from an anaesthesia workstation exhaust (when set to minimal flow and end-tidal control mode) was evaluated in 70 adult patients scheduled for general or bariatric laparoscopic surgery. The weight of the sevoflurane vaporiser and CONTRAfluran canister was measured before and after each case, to calculate total sevoflurane consumption and retention. Retention was measured after the minimal flow maintenance phase and after the high flow washout phase. The total retention efficiency was the fraction of all consumed sevoflurane captured by the CONTRAfluran canister. The primary objective was to examine the retention efficiency of CONTRAfluran in a clinical surgical setting, where all feasible strategies to minimise sevoflurane consumption and optimise the efficacy of CONTRAfluran were utilised. The secondary objective was to analyse the correlation between mass transfer and the duration of the case. Mean (SD) volume of sevoflurane captured using CONTRAfluran was 4.82 (1.41) ml, representing 45% (95%CI 42-48%) of all sevoflurane administered. The highest amount of retention was found during the washout phase. Retention efficiency did not correlate with the duration of the case. Over half of the sevoflurane administered was not captured by the CONTRAfluran canister when minimal flow techniques were used, likely due to residual accumulation of sevoflurane in the patient after tracheal extubation or, to a lesser extent, due to ventilation system leakage. However, as every prevented emission is commendable, CONTRAfluran may be a potentially valuable tool for reducing the environmental footprint of sevoflurane-based anaesthesia.

Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial

BackgroundDelirium is a common and disturbing postoperative complication that might be ameliorated by propofol-based anaesthesia. We therefore tested the primary hypothesis that there is less delirium after propofol-based than after sevoflurane-based anaesthesia within 7 days of major cancer surgery. MethodsThis multicentre randomised trial was conducted in 14 tertiary care hospitals in China. Patients aged 65–90 yr undergoing major cancer surgery were randomised to either propofol-based anaesthesia or to sevoflurane-based anaesthesia. The primary endpoint was the incidence of delirium within 7 postoperative days. ResultsA total of 1228 subjects were enrolled and randomised, with 1195 subjects included in the modified intention-to-treat analysis (mean age 71 yr; 422 [35%] women); one subject died before delirium assessment. Delirium occurred in 8.4% (50/597) of subjects given propofol-based anaesthesia vs 12.4% (74/597) of subjects given sevoflurane-based anaesthesia (relative risk 0.68 [95% confidence interval {CI}: 0.48–0.95]; P=0.023; adjusted relative risk 0.59 [95% CI: 0.39–0.90]; P=0.014). Delirium reduction mainly occurred on the first day after surgery, with a prevalence of 5.4% (32/597) with propofol anaesthesia vs 10.7% (64/597) with sevoflurane anaesthesia (relative risk 0.50 [95% CI: 0.33–0.75]; P=0.001). Secondary endpoints, including ICU admission, postoperative duration of hospitalisation, major complications within 30 days, cognitive function at 30 days and 3 yr, and safety outcomes, did not differ significantly between groups. ConclusionsDelirium was a third less common after propofol than sevoflurane anaesthesia in older patients having major cancer surgery. Clinicians might therefore reasonably select propofol-based anaesthesia in patients at high risk of postoperative delirium. Clinical trial registrationChinese Clinical Trial Registry (ChiCTR-IPR-15006209) and ClinicalTrials.gov (NCT02662257).

Long-term survival in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: follow-up of a multicentre randomised trial

BackgroundExperimental evidence indicates that i.v. anaesthesia might reduce cancer recurrence compared with volatile anaesthesia, but clinical information is observational only. We therefore tested the primary hypothesis that propofol-based anaesthesia improves survival over 3 or more years after potentially curative major cancer surgery. MethodsThis was a long-term follow-up of a multicentre randomised trial in 14 tertiary hospitals in China. We enrolled 1228 patients aged 65–90 yr who were scheduled for major cancer surgery. They were randomised to either propofol-based i.v. anaesthesia or to sevoflurane-based inhalational anaesthesia. The primary endpoint was overall survival after surgery. Secondary endpoints included recurrence-free and event-free survival. ResultsAmongst subjects randomised, 1195 (mean age 72 yr; 773 [65%] male) were included in the modified intention-to-treat analysis. At the end of follow-up (median 43 months), there were 188 deaths amongst 598 patients (31%) assigned to propofol-based anaesthesia compared with 175 deaths amongst 597 patients (29%) assigned to sevoflurane-based anaesthesia; adjusted hazard ratio 1.02; 95% confidence interval (CI): 0.83–1.26; P=0.834. Recurrence-free survival was 223/598 (37%) in patients given propofol anaesthesia vs 206/597 (35%) given sevoflurane anaesthesia; adjusted hazard ratio 1.07; 95% CI: 0.89–1.30; P=0.465. Event-free survival was 294/598 (49%) in patients given propofol anaesthesia vs 274/597 (46%) given sevoflurane anaesthesia; adjusted hazard ratio 1.09; 95% CI 0.93 to 1.29; P=0.298. ConclusionsLong-term survival after major cancer surgery was similar with i.v. and volatile anaesthesia. Propofol-based iv. anaesthesia should not be used for cancer surgery with the expectation that it will improve overall or cancer-specific survival. Clinical trial registrationsChiCTR-IPR-15006209; NCT02660411.

Electroencephalographic delta and alpha oscillations reveal phase-amplitude coupling in paediatric patients undergoing sevoflurane-based general anaesthesia

BackgroundSevoflurane-induced anaesthesia generates frontal alpha oscillations as early as 6 months of age, whereas strong delta oscillations are present at birth. In adults, delta oscillations and alpha oscillations are coupled: the phase of delta waves modulates the amplitude of alpha oscillations in a phenomenon known as phase-amplitude coupling. We hypothesise that delta-alpha phase-amplitude coupling exists in young children and is a feature of sevoflurane-based general anaesthesia distinct from emergence after anaesthesia. MethodsElectroencephalographic data from 31 paediatric patients aged 10 months to 3 yr undergoing elective surgery with sevoflurane-based anaesthesia were analysed retrospectively. Delta-alpha phase-amplitude coupling was evaluated during maintenance of anaesthesia and during emergence. ResultsDelta-alpha phase-amplitude coupling was observed in the study population. Strength of phase-amplitude coupling, represented by the delta-alpha mean amplitude vector, was greater during general anaesthesia than during emergence (Wilcoxon paired signed-rank test, Z=3.107, P=0.002). Frontal alpha amplitude during anaesthesia was not uniformly distributed across all delta phases. During general anaesthesia, alpha power was restricted to the positive phase of the delta wave (omnibus circular uniformity, general anaesthesia: P<0.001, mean phase: 114º; 99% confidence interval: 90º–139º; emergence: P=0.35, mean phase 181º, 99% confidence interval: 110º–253º). ConclusionsSevoflurane-based anaesthesia is associated with delta-alpha phase-amplitude coupling in paediatric patients. These findings improve our understanding of cortical dynamics in children undergoing general anaesthesia, which might improve paediatric intraoperative depth of anaesthesia monitoring techniques.

Neurocardiovascular coupling in congenital diaphragmatic hernia patients undergoing different types of surgical treatment.

BACKGROUNDThe effect of peri-operative management on the neonatal brain is largely unknown. Triggers for perioperative brain injury might be revealed by studying changes in neonatal physiology peri-operatively.OBJECTIVETo study neonatal pathophysiology and cerebral blood flow regulation peri-operatively using the neuro-cardiovascular graph.DESIGNObservational, prospective cohort study on perioperative neuromonitoring. Neonates were included between July 2018 and April 2020.SETTINGMulticentre study in two high-volume tertiary university hospitals.PATIENTSNeonates with congenital diaphragmatic hernia were eligible if they received surgical treatment within the first 28 days of life. Exclusion criteria were major cardiac or chromosomal anomalies, or syndromes associated with altered cerebral perfusion or major neurodevelopmental impairment. The neonates were stratified into different groups by type of peri-operative management.INTERVENTIONEach patient was monitored using near-infrared spectroscopy and EEG in addition to the routine peri-operative monitoring. Neurocardiovascular graphs were computed off-line.MAIN OUTCOME MEASURESThe primary endpoint was the difference in neurocardiovascular graph connectivity in the groups over time.RESULTSThirty-six patients were included. The intraoperative graph connectivity decreased in all patients operated upon in the operation room (OR) with sevoflurane-based anaesthesia (P < 0.001) but remained stable in all patients operated upon in the neonatal intensive care unit (NICU) with midazolam-based anaesthesia. Thoracoscopic surgery in the OR was associated with the largest median connectivity reduction (0.33 to 0.12, P < 0.001) and a loss of baroreflex and neurovascular coupling. During open surgery in the OR, all regulation mechanisms remained intact. Open surgery in the NICU was associated with the highest neurovascular coupling values.CONCLUSIONNeurocardiovascular graphs provided more insight into the effect of the peri-operative management on the pathophysiology of neonates undergoing surgery. The neonate's clinical condition as well as the surgical and the anaesthesiological approach affected the neonatal physiology and CBF regulation mechanisms at different levels.TRIAL REGISTRATIONNL6972, URL: https://www.trialre-gister.nl/trial/6972.

Protective effect of sevoflurane on vascular endothelial glycocalyx in patients undergoing heart valve surgery: A randomised controlled trial.

The glycocalyx plays an important physiological role and may be damaged during cardiopulmonary bypass. Sevoflurane can protect the glycocalyx; however, its relevance in a clinical setting is unknown. Glycocalyx degradation during cardiopulmonary bypass in patients was investigated. On the basis of the available experimental data, we hypothesised that sevoflurane-based anaesthesia would confer additional protection against cardiopulmonary bypass-induced glycocalyx damage. Randomised controlled study. Clinical study at The First Affiliated Hospital of Wenzhou Medical University between June 2018 and March 2019. Fifty-one patients. After intubation and mechanical ventilation, patients undergoing elective heart valve surgery were maintained under general anaesthesia with either propofol or sevoflurane during surgery. Glycocalyx markers (such as syndecan-1, heparan sulphate and hyaluronan), sheddases responsible for the degradation of the endothelial glycocalyx (such as matrix metalloproteinase-9 and cathepsin-B), urine albumin-to-creatinine ratio and levels of lactic acid and myocardial enzymes were all measured. Postoperative mechanical ventilation time and length of stay in the cardiac care unit and hospital were also measured. Morbidity and mortality after 30 days and 1 year were evaluated. The vascular endothelial glycocalyx was damaged during cardiopulmonary bypass. The glycocalyx damage in the sevoflurane group was less extensive than that in the propofol group. The urine albumin-to-creatinine ratio increased in both groups but was lower in the sevoflurane group. Enzymes including matrix metalloproteinase-9 and cathepsin-B were positively correlated with glycocalyx marker concentrations. After operation, the sevoflurane group showed lower levels of lactic acid and myocardial enzyme, as well as shorter duration of postoperative mechanical ventilation than the propofol group. Sevoflurane can decrease glycocalyx degradation in patients undergoing heart valve surgery under cardiopulmonary bypass. Chinese Clinical Trial Registry, chictr.org.cn, identifier: ChiCTR1800016367.

Adverse respiratory events with sevoflurane compared with desflurane in ambulatory surgery: A systematic review and meta-analysis.

BACKGROUNDAn increasing number of studies have concluded that the number of adverse events in the upper airway caused by desflurane does not differ significantly from the number of adverse events caused by sevoflurane. The advantages of desflurane in ambulatory surgery should be reassessed.OBJECTIVESThe aim of this study was to compare adverse respiratory events and recovery outcomes in patients undergoing desflurane or sevoflurane-based anaesthesia in ambulatory surgery.DESIGNA systematic review and meta-analysis of randomised controlled trials (RCTs).DATA SOURCESA systematic search for eligible RCTs in PubMed, Medline, Cochrane Central Register of Controlled Trials, ScienceDirect and Embase published up to June 2019.ELIGIBILITY CRITERIARCTs investigating the occurrence of adverse respiratory events, including airway irritation, stridor, coughing, respiratory distress and laryngospasm, emergence agitation, postoperative nausea and vomiting (PONV), time to eye opening and time to discharge from the operation room after desflurane or sevoflurane-based anaesthesia.RESULTSThirteen trials were included and analysed. A total of 634 patients were included in the desflurane group, and 633 patients in the sevoflurane group. The occurrence of respiratory complications was significantly higher with desflurane-based anaesthesia than with sevoflurane-based anaesthesia (Total n = 673, 20.0 vs. 12.8%, relative risk (RR) 1.59 (95% CI 1.15 to 2.20)) with low heterogeneity (I2 = 20%). There was no difference in the occurrence of emergence agitation (Total n = 626, 29.1 vs. 27.2%, RR 1.05 (95% CI 0.84 to 1.30)) or the incidence of PONV between the desflurane and sevoflurane groups (Total n = 989, 19.0 vs. 21.0%, RR 0.95 (95% CI 0.71 to 1.26)). Time to eye opening was significantly faster with desflurane than that with sevoflurane (Total n = 1072, mean difference = −3.32 min (95% CI −4.02 to −2.61)) with a substantial heterogeneity (I2 = 72.6%). There was no significant difference in the time to discharge from the operation room between the two groups (Total n = 1056, mean difference = −0.45 min (95% CI −5.89 to 4.99)).CONCLUSIONDespite recent reports that there is no significant difference in adverse respiratory events between desflurane and sevoflurane, a pooled analysis revealed that desflurane resulted in a higher rate than sevoflurane. Therefore, the consequences of desflurane should not be neglected and its airway irritant properties should be taken into account.TRIAL REGISTRATIONPROSPERO (CRD42019147939).

Systemic Oxygen Delivery during One-Lung Ventilation: Comparison between Propofol and Sevoflurane Anaesthesia in a Randomised Controlled Trial.

Systemic oxygen delivery (DO2) is a more comprehensive marker of patient status than arterial oxygen saturation (SaO2), and DO2 in the range of 330–500 mL min−1 is reportedly adequate during anaesthesia. We measured DO2 during one-lung ventilation (OLV) for thoracic surgery—where the risk of pulmonary shunt is significant, and hypoxia occurs frequently—and compared sevoflurane and propofol, the two most commonly used anaesthetics in terms of DO2. Sevoflurane impairs hypoxic pulmonary vasoconstriction. Thus, our hypothesis was that propofol-based anaesthesia would show a higher DO2 value than sevoflurane-based anaesthesia. This was a double-blinded randomised controlled trial conducted at a university hospital from 2017 to 2018. The study population consisted of patients scheduled for lobectomy under OLV (N = 120). Sevoflurane or propofol was titrated to a bispectral index of 40–50. Haemodynamic variables were measured during two-lung ventilation (TLV) and OLV at 15 and 45 min (OLV15 and OLV45, respectively) using oesophageal Doppler monitoring. The mean DO2 (mL min−1) was not different between the sevoflurane and propofol anaesthesia groups (TLV: 680 vs. 706; OLV15: 685 vs. 703; OLV45: 759 vs. 782, respectively). SaO2 was not correlated with DO2 (r = 0.09, p = 0.100). Patients with SaO2 < 94% showed adequate DO2 (641 ± 203 mL min−1), and patients with high SaO2 (> 97%) showed inadequate DO2 (14% of measurements < 500 mL min−1). In conclusion, DO2 did not significantly differ between sevoflurane and propofol. SaO2 was not correlated with DO2 and was not informative regarding whether the patients were receiving an adequate oxygen supply. DO2 may provide additional information on patient status, which may be especially important when patients show a low SaO2.

Sevoflurane based anaesthesia does not affect already impaired cerebral autoregulation in patients with type 2 diabetes mellitus

BackgroundThe baroreflex regulates arterial blood pressure (BP). During periods when blood pressure changes, cerebral blood flow (CBF) is kept constant by cerebral autoregulation (CA). In patients with diabetes mellitus (DM), low baroreflex sensitivity (BRS) is associated with impaired CA. As sevoflurane-based anaesthesia obliterates BRS, we hypothesised that this could aggravate the already impaired CA in patients with DM resulting in a ‘double-hit’ on cerebral perfusion leading to increased fluctuations in blood pressure and cerebral perfusion. MethodsOn the day before surgery, we measured CBF velocity (CBFV), heart rate, and BP to determine BRS and CA efficacy (CBFVmean-to-BPmean-phase lead) in 25 patients with DM and in 14 controls. During the operation, BRS and CA efficacy were determined during sevoflurane-based anaesthesia. Patients with DM were divided into a group with high BRS (DMBRS↑) and a group with low BRS (DMBRS↓). Values presented are median (inter-quartile range). ResultsPreoperative vs intraoperative BRS was 6.2 (4.5–8.5) vs 1.9 (1.1–2.5, P<0.001) ms mm Hg−1 for controls, 5.8 (4.9–7.6) vs 2.7 (1.5–3.9, P<0.001) ms mm Hg−1 for patients with DMBRS↑, and 1.9 (1.5–2.8) vs 1.1 (0.6–2.5, P=0.31) ms mm Hg−1 for patients with DMBRS↓. Preoperative vs intraoperative CA efficacy was 43° (38–46) vs 43° (38–51, P=0.30), 44° (36–49) vs 41° (32–49, P=0.52), and 34° (28–40) vs 30° (27–38, P=0.64) for controls, DMBRS↑, and DMBRS↓ patients, respectively. ConclusionsIn diabetic patients with low preoperative BRS, preoperative CA efficacy was also impaired. In controls and diabetic patients, CA was unaffected by sevoflurane-based anaesthesia. We therefore conclude that sevoflurane-based anaesthesia does not contribute to a ‘double-hit’ phenomenon on cerebral perfusion. Clinical trial registrationNCT 03071432.

Comparison of the expression of cluster of differentiation (CD)39 and CD73 between propofol- and sevoflurane-based anaesthesia during open heart surgery

High expression of cluster of differentiation (CD)39 and CD73 has cardio-protective effects. We hypothesised that the expression of CD39 and CD73 would differ between propofol- and volatile anaesthetic-based anaesthesia in patients undergoing open heart surgery (OHS). The objective of this prospective randomized trial was to compare the changes in CD39 and CD73 levels in CD4+ T cells between propofol- and sevoflurane-based anaesthesia during OHS. The study randomly allocated 156 patients undergoing OHS to a propofol or sevoflurane group. Blood was obtained preoperatively and up to 48 hours after weaning from cardiopulmonary bypass (CPB). The expression levels of CD39 and CD73 in circulating CD4+ T cells, serum cytokines and other laboratory parameters were analysed. The primary outcome was the expression of CD39 and CD73 on CD4+ T cells. Demographic data and perioperative haemodynamic changes did not show significant differences between the two groups. The expression of CD39 and CD73 in the sevoflurane group was significantly lower than in the propofol group (P < 0.001). Other laboratory findings including cardiac enzymes and cytokine levels, did not show significant intergroup differences. Propofol attenuated the decrease in CD39 and CD73 in circulating CD4+ T cells compared to sevoflurane-based anaesthesia during OHS.

The effect of propofol and sevoflurane on cancer cell, natural killer cell, and cytotoxic T lymphocyte function in patients undergoing breast cancer surgery: an in vitro analysis

BackgroundTo clarify the effect of anaesthetic agents on cancer immunity, we evaluated the effects of propofol and sevoflurane on natural killer (NK) cell, cytotoxic T lymphocyte (CTL) counts and apoptosis rate in breast cancer and immune cells co-cultures from patients who underwent breast cancer surgery.MethodsVenous blood samples were collected after inducing anaesthesia and at 1 and 24 h postoperatively in patients who had undergone breast cancer surgery. The patients were allocated randomly to the propofol- or sevoflurane-based anaesthesia groups. We counted and detected apoptosis in cancer cell, NK cell and CTL of patients with breast cancer by co-culture with a breast cancer cell line in both groups. We also evaluated changes in the cytokines tumour necrosis factor-alpha, interleukin (IL)-6 and IL-10 during the perioperative period.ResultsForty-four patients were included in the final analysis. No difference in NK cell count, CTL count or apoptosis rate was detected between the groups. Furthermore, the number of breast cancer cells undergoing apoptosis in the breast cancer cell co-cultures was not different between the groups. No changes in cytokines were detected between the groups.ConclusionAlthough basic science studies have suggested the potential benefits of propofol over a volatile agent during cancer surgery, propofol was not superior to sevoflurane, on the aspects of NK and CTL cells counts with apoptosis rate including breast cancer cell, during anaesthesia for breast cancer surgery in a clinical environment.Trial registrationNCT02758249 on February 26, 2016.

Effect of anaesthetic agents on olfactory threshold and identification - A single blinded randomised controlled study.

Background and Aims:Anaesthetics are implicated in cognitive dysfunction, taste and odour deficits in the postoperative period. We aimed to assess the effect of isoflurane, sevoflurane, propofol and regional anaesthesia on the olfactory threshold, olfactory identification and endocrine regulation of associative memory in the postoperative period.Methods:In this observer-blinded randomised controlled study, 164 patients (>50 years) with the American Society of Anesthesiologists I and II status were randomised into one of four groups to receive regional anaesthesia, general anaesthesia with sevoflurane, general anaesthesia with isoflurane and total intravenous anaesthesia with propofol. Hindi Mental State Examination, olfactory threshold and olfactory identification were tested at 12 h preoperatively (T0), at 3 h postoperatively (T1) and at the time of discharge or postoperative day 3 (T2). In addition, serum melatonin levels were estimated at T0 and T1. The olfactory threshold was tested with n-butyl alcohol and olfactory identification with the University of Pennsylvania Smell Identification Test (UPSIT). Data were analysed using the one-way analysis of variance, Kruskal-Wallis or Mann-whitney tests.Results:The olfactory identification scores were lower with patients receiving sevoflurane-based anaesthesia at 3 h postoperatively (T1) when compared to preoperative (T0) (median 19.5 vs. 22; P = 0.01). This was accompanied by a significant postoperative reduction of plasma melatonin levels in sevoflurane group when compared to other groups (17.34 ± 4.8 pg/ml vs 23.2 ± 3.5 pg/ml; P < 0.001).Conclusion:Sevoflurane was associated with short-term olfactory identification impairment with a concomitant reduction in melatonin levels illustrating a possible humoral mechanism.

Propofol-based anaesthesia versus sevoflurane-based anaesthesia for living donor kidney transplantation: results of the VAPOR-1 randomized controlled trial

BackgroundKidney transplantation is associated with harmful processes affecting the viability of the graft. One of these processes is associated with the phenomenon of ischaemia–reperfusion injury. Anaesthetic conditioning is a widely described strategy to attenuate ischaemia–reperfusion injury. We therefore conducted the Volatile Anaesthetic Protection of Renal Transplants-1 trial, a pilot project evaluating the influence of two anaesthetic regimens, propofol- vs sevoflurane-based anaesthesia, on biochemical and clinical outcomes in living donor kidney transplantation. MethodsSixty couples were randomly assigned to the following three groups: PROP (donor and recipient propofol), SEVO (donor and recipient sevoflurane), and PROSE (donor propofol and recipient sevoflurane). The primary outcome was renal injury reflected by urinary biomarkers. The follow-up period was 2 yr. ResultsThree couples were excluded, leaving 57 couples for analysis. Concentrations of kidney injury molecule-1 (KIM-1), N-acetyl-β-d-glucosaminidase (NAG), and heart-type fatty acid binding protein (H-FABP) in the first urine upon reperfusion showed no differences. On day 2, KIM-1 concentrations were higher in SEVO [952.8 (interquartile range 311.8–1893.0) pg mmol−1] compared with PROP [301.2 (202.0–504.7) pg mmol−1]. This was the same for NAG: SEVO, 1.835 (1.162–2.457) IU mmol−1vs PROP, 1.078 (0.819–1.713) IU mmol−1. Concentrations of H-FABP showed no differences. Measured glomerular filtration rate at 3, 6, and 12 months showed no difference. After 2 yr, there was a difference in the acute rejection rate (P=0.039). Post hoc testing revealed a difference between PROP (35%) and PROSE (5%; P=0.020). The difference between PROP and SEVO (11%) was not significant (P=0.110). ConclusionsThe SEVO group showed higher urinary KIM-1 and NAG concentrations in living donor kidney transplantation on the second day after transplantation. This was not reflected in inferior graft outcome. Clinical trial registrationNCT01248871.

Biomarkers of inflammation in major vascular surgery: a prospective randomised trial

Surgery induces inflammation and pro-inflammatory cytokines are associated with post-operative complications. In cardiac surgery, it has been shown that volatile anaesthetics have cardioprotective properties. We explored whether sevoflurane affects the pro-inflammatory response favourably compared with total intravenous anaesthesia (TIVA) after surgery. We measured monocyte chemotactic protein 1 (MCP-1), matrix metalloproteinase 9 (MMP-9), C-reactive protein (CRP), vascular cell adhesion molecule 1 (VCAM-1), interleukin (IL)-6 and IL-8 perioperatively and evaluated if the anaesthetic regimen affected these mediators. Our hypothesis was that sevoflurane-based anaesthesia is associated with a reduced release of biomarkers of inflammation compared with TIVA with propofol/remifentanil. In the total population, MCP-1, MMP-9, IL-6 and IL-8 increased 30 min after arrival intensive care unit, compared with before surgery (P < 0.001), whereas CRP and VCAM-1 transiently declined (P < 0.001). From 30 min after arrival intensive care unit to 1st post-operative day, MCP-1 and IL-6 levels declined (P < 0.001), CRP and VCAM-1 increased (P < 0.001), whereas MMP-9 and IL-8 were not significantly altered. Pre-operatively there were no significant differences in any variables between the two anaesthetic groups. Lower levels of MCP-1 and IL-8 (P < 0.001) and higher levels of IL-6 and MMP-9 (P = 0.003) were found in the sevoflurane group, compared with the TIVA group 30 min post-operatively. CRP and VCAM-1 levels did not differ. There were no significant differences between the two anaesthetic groups before surgery or at 1st post-operative day. We found an inflammatory response during the observation period, which was modified by the anaesthetic regimen in the early phase. This short-lasting difference is probably too short to support a cardioprotective effect of sevoflurane compared with TIVA in open abdominal aortic surgery.

Analgesia Nociception Index (ANI) to predict intraoperative haemodynamic changes: results of a pilot investigation

The Analgesia Nociception Index has been described to reflect different levels of intraoperative nociceptive stimulation during total intravenous anaesthesia. The association between this index and haemodynamic changes during sevoflurane-based anaesthesia was investigated in 30 patients with the hypothesis that changes in the Analgesia Nociception Index may coincide with or even predict haemodynamic changes. The Analgesia Nociception Index as well as blood pressure and heart rate were observed during induction, at skin incision, at times of an Analgesia Noceception Index decrease > 20% ('event') and pre-/post-fentanyl administration. The Analgesia Nociception Index decreased with airway manipulation [mean: 52 (before) vs. 33 (after); P < 0.005] and after skin incision [mean: 63 (before) vs. 38 (after); P < 0.001], and it increased after fentanyl administration [53 (before) vs. 59 (after); P < 0.05]. However, its predictive probability to indicate heart rate and blood pressure increases of >10% was low (heart rate 0.61; blood pressure 0.59). The Analgesia Nociception Index appears to reflect different levels of stimulation during sevoflurane-based general anaesthesia. However, it was of little predictive value to pre-empt significant haemodynamic changes.

Tropisetron alleviate early post‐operative pain after gynecological laparoscopy in sevoflurane based general anaesthesia: A randomized, parallel‐group, factorial study

Studies have suggested that 5-hydroxytryptamine-3A (5-HT-3A) receptor antagonists may have analgesic effects. This randomized, double-blind, placebo-controlled, factorial study tested the hypothesis that 5-HT-3A receptor antagonist tropisetron attenuates post-operative pain in women receiving either sevoflurane or propofol based anaesthesia. Two hundred and ninety-six women undergoing gynaecological laparoscopies were randomly assigned to be anaesthetized with either sevoflurane or propofol. Immediately after the induction of anaesthesia, the anaesthesiologist administered either tropisetron 2 mg or a placebo intravenously. Pain score at rest at 0.5 h post-operatively reported using a numerical rating scale was the primary outcome measure. The secondary outcome measures included pain score at rest every 2 h within the first 24 h post-operatively, duration of post-anaesthesia care unit stay, incidence of post-operative nausea and vomiting, the incidence of shivering and score of the Quality of Recovery Score 40. Compared with placebo, tropisetron produced a statistically significant decrease on pain report within the first 6 h post-operatively in the sevoflurane-based anaesthesia group (3 [2, 4] vs. 5 [4, 5], p < 0.001 in 0.5 h; 2 [0, 4] vs. 3 [3, 5], p < 0.001 in 2 h; 2 [0, 3] vs. 3 [1, 4], p = 0.002 in 4 h; 1 [0, 3] vs. 2 [1, 4], p = 0.016 in 6 h), but not in the propofol-based group. A single-dose intravenous administration of tropisetron after anaesthesia induction is associated with statistically significant decreased early post-operative pain in patients undergoing gynaecological laparoscopies under sevoflurane based general anaesthesia.

Cognitive function after sevoflurane- vs propofol-based anaesthesia for on-pump cardiac surgery: a randomized controlled trial

Cognitive dysfunction is a frequent complication after cardiac surgery and has been found to be associated with decreases in cerebral oxygen saturation measured with near-infrared spectroscopy. Sevoflurane has neuroprotective properties in vitro and in animal models. This study was designed to determine cognitive and clinical outcomes after sevoflurane- compared with propofol-based anaesthesia for on-pump cardiac surgery and the impact of decreases in under different anaesthesia regimens. One hundred and twenty-eight patients were randomly assigned to either i.v. anaesthesia with propofol- (PROP) or sevoflurane-based anaesthesia (SEVO). An intraoperative was defined as desaturation. The Abbreviated Mental Test, Stroop Test, Trail-Making Test, Word Lists, and mood-assessment tests were performed before, 2, 4, and 6 days after cardiac surgery. Markers of general outcome were obtained. The analysis groups had differences in baseline cognitive performance. Analysis of variance for repeated measures (incorporating covariance of baseline scores) showed that in three of four cognitive tests, patients with cerebral desaturation showed worse results than patients without desaturation. Patients assigned to sevoflurane-based anaesthesia showed better results in all cognitive tests than patients after propofol. Interactions between the anaesthetic regimen and desaturation were found in all four cognitive tests. There were no differences in markers of organ dysfunction or general clinical outcome. Patients with impaired cognitive performance before operation may be at particular risk for intraoperative cerebral insult. A sevoflurane-based anaesthesia was associated with better short-term postoperative cognitive performance than propofol.

A randomized controlled trial comparing an intraoperative goal-directed strategy with routine clinical practice in patients undergoing peripheral arterial surgery

We hypothesized that, in vascular surgery patients, the application of a goal-directed strategy based on a pulse contour-derived cardiac index would be associated with a better haemodynamic status than the application of routine perioperative care and that the amount of fluid and/or inotropes required in such a goal-directed therapy depended on the general anaesthetic technique used. Patients undergoing peripheral arterial bypass grafting were randomly assigned to three groups. In group 1, haemodynamic management was performed according to routine clinical practice. In the two other groups (groups 2 and 3) a goal-directed therapy was applied aiming to maintain the pulse contour-derived cardiac index above 2.5 l m min. Patients in groups 1 and 2 received sevoflurane-based anaesthesia and patients in group 3 propofol-based anaesthesia. Haemodynamic variables, amount of fluid and administration of inotropes were assessed at different time intervals. The amount of fluid administered was not significantly different between the groups. Two patients in group 1, 13 patients in group 2 and 12 patients in group 3 were treated with dobutamine (P < 0.001). None of the patients anaesthetized with sevoflurane (groups 1 and 2) experienced postoperative cardiovascular complications, whereas four patients in the total intravenous group (group 3) experienced major postoperative cardiovascular complications (P = 0.005). In the conditions of the present study, the application of a goal-directed therapy aiming to maintain the cardiac index above 2.5 l min m did not result in a higher tissue oxygen delivery than when applying the standard haemodynamic strategy nor did it depend on the anaesthetic technique used.

Comparison of the effects of sevoflurane and propofol on cooling and rewarming during deliberate mild hypothermia for neurosurgery.

Background Because the time available for cooling and rewarming during deliberate mild hypothermia is limited, studies of the rate of the cooling and rewarming are useful. The decrease in core hypothermia caused by heat redistribution depends on the anaesthetic agent used. We therefore investigated possible differences between sevoflurane and propofol on the decrease and recovery of core temperature during deliberate mild hypothermia for neurosurgery. Methods After institutional approval and informed consent, 26 patients were assigned randomly to maintenance of anaesthesia with propofol or sevoflurane. Patients in the propofol group (n=13) received propofol induction followed by a continuous infusion of propofol 3–5 mg kg−1 h−1. Patients in the sevoflurane group (n=13) received propofol induction followed by sevoflurane 1–2%. Nitrous oxide and fentanyl were also used for anaesthetic maintenance. After induction of anaesthesia, patients were cooled and tympanic membrane temperature was maintained at 34.5°C. After surgery, patients were actively rewarmed. Results There was no difference in the rate of decrease and recovery of core temperature between the groups. There was also no difference in skin surface temperature gradient (forearm to fingertip), heart rate and mean arterial blood pressure between the groups. Conclusions Sevoflurane-based anaesthesia did not affect cooling and rewarming for deliberate mild hypothermia compared with propofol-based anaesthesia.

Comparison of the effects of sevoflurane and propofol on cooling and rewarming during deliberate mild hypothermia for neurosurgery

BackgroundBecause the time available for cooling and rewarming during deliberate mild hypothermia is limited, studies of the rate of the cooling and rewarming are useful. The decrease in core hypothermia caused by heat redistribution depends on the anaesthetic agent used. We therefore investigated possible differences between sevoflurane and propofol on the decrease and recovery of core temperature during deliberate mild hypothermia for neurosurgery.MethodsAfter institutional approval and informed consent, 26 patients were assigned randomly to maintenance of anaesthesia with propofol or sevoflurane. Patients in the propofol group (n=13) received propofol induction followed by a continuous infusion of propofol 3–5 mg kg−1 h−1. Patients in the sevoflurane group (n=13) received propofol induction followed by sevoflurane 1–2%. Nitrous oxide and fentanyl were also used for anaesthetic maintenance. After induction of anaesthesia, patients were cooled and tympanic membrane temperature was maintained at 34.5°C. After surgery, patients were actively rewarmed.ResultsThere was no difference in the rate of decrease and recovery of core temperature between the groups. There was also no difference in skin surface temperature gradient (forearm to fingertip), heart rate and mean arterial blood pressure between the groups.ConclusionsSevoflurane-based anaesthesia did not affect cooling and rewarming for deliberate mild hypothermia compared with propofol-based anaesthesia. Because the time available for cooling and rewarming during deliberate mild hypothermia is limited, studies of the rate of the cooling and rewarming are useful. The decrease in core hypothermia caused by heat redistribution depends on the anaesthetic agent used. We therefore investigated possible differences between sevoflurane and propofol on the decrease and recovery of core temperature during deliberate mild hypothermia for neurosurgery. After institutional approval and informed consent, 26 patients were assigned randomly to maintenance of anaesthesia with propofol or sevoflurane. Patients in the propofol group (n=13) received propofol induction followed by a continuous infusion of propofol 3–5 mg kg−1 h−1. Patients in the sevoflurane group (n=13) received propofol induction followed by sevoflurane 1–2%. Nitrous oxide and fentanyl were also used for anaesthetic maintenance. After induction of anaesthesia, patients were cooled and tympanic membrane temperature was maintained at 34.5°C. After surgery, patients were actively rewarmed. There was no difference in the rate of decrease and recovery of core temperature between the groups. There was also no difference in skin surface temperature gradient (forearm to fingertip), heart rate and mean arterial blood pressure between the groups. Sevoflurane-based anaesthesia did not affect cooling and rewarming for deliberate mild hypothermia compared with propofol-based anaesthesia.