Inhalational or total intravenous anaesthesia: is total intravenous anaesthesia useful and are there economic benefits?

Anaesthesia and climate change: time to wake up? A rapid qualitative appraisal exploring the views of anaesthetic practitioners regarding the transition to TIVA and the reduction of desflurane

BACKGROUND

The National Health Service (NHS) has pledged to reach carbon net-zero by 2040. In alignment with this goal, a London hospital's anaesthesia department is actively reducing desflurane use and transitioning towards total intravenous anaesthesia (TIVA) as a sustainable alternative, contributing to environmentally responsible practices within the healthcare sector.

METHODS

We conducted a rapid qualitative appraisal through online interviews with 17 anaesthetic practitioners to explore their perspectives regarding this climate change mitigation strategy. Data analysis was undertaken through the use of rapid appraisal sheets and a framework analysis method.

RESULTS

Participants highlighted the disadvantages of TIVA, including the increased effort, heightened monitoring requirements, operational challenges, and a lack of clinical confidence associated with its use. Despite these reservations, participants acknowledged TIVA's potential to reduce postoperative nausea. There were perceptions that senior staff members might resist this change due to habits and scepticism over its impact on climate change. To facilitate greater TIVA adoption, participants recommended enhanced training, the implementation of a dashboard to raise awareness of greenhouse gas (GHG) emissions, and the presence of strong climate change leadership within the department. Participants believed that a shift to TIVA should be followed by specific measures such as addressing waste management which is crucial for GHG reduction, emphasising the perceived link between waste and emissions.

CONCLUSIONS

The evaluation examines stakeholder attitudes, perceptions, and behaviours, focusing on transitioning from desflurane to TIVA. The study highlights the importance of staff engagement, organisational support, and underscores the crucial role that healthcare practitioners and leadership play in fostering sustainability within the healthcare sector.

Impact of inhalational anesthetic agents on the baseline monitorability of motor evoked potentials during spine surgery: a review of 22,755 cervical and lumbar procedures

BACKGROUND CONTEXT

During spine surgery, motor evoked potentials (MEPs) are often utilized to monitor both spinal cord function and spinal nerve root or plexus function. While there are reports evaluating the impact of anesthesia on the ability of MEPs to monitor spinal cord function, less is known about the impact of anesthesia on the ability of MEPs to monitor spinal nerve root and plexus function.

PURPOSE

To compare the baseline monitorability and amplitude of MEPs during cervical and lumbar procedures between two cohorts based on the maintenance anesthetic regimen: a total intravenous anesthesia (TIVA) versus a regimen balanced with volatile inhalational and intravenous agents.

STUDY DESIGN

Baseline MEP data from a total of 16,559 cervical and 6,196 lumbar extradural spine procedures utilizing multimodality intraoperative neuromonitoring (IONM) including MEPs between January 2017 and March 2020 were obtained from a multi-institutional database. Two cohorts for each region of spine surgery were delineated based on the anesthetic regimen: a TIVA cohort and a Balanced anesthesia cohort.

PATIENT SAMPLE

Age 18 and older. Fellowship support for 65,000 for year 2021.

OUTCOME MEASURES

Percent monitorability and amplitudes of baseline MEPs.

METHODS

The baseline monitorability of each muscle MEP was evaluated by the IONM team in real-time and recorded in the patient's electronic medical record. The relation between anesthetic regimen and baseline monitorability was estimated using mixed effects logistic regression, with distinct models for cervical and lumbar procedures. Subsets of cervical and lumbar procedures from each anesthesia cohort in which all MEPs were deemed monitorable were randomly selected and the average peak-to-trough amplitude of each muscle MEP was retrospectively measured. Mixed-effects linear regression models were estimated (one each for cervical and lumbar procedures) to assess possible differences in average amplitude associated with anesthesia regimen.

RESULTS

At the time of surgery, baseline MEPs were reported monitorable from all targeted muscles in 86.8% and 83.0% of cervical and lumbar procedures, respectively, for the TIVA cohort, but were reported monitorable in just 59.3% and 61.0% of cervical and lumbar procedures, respectively, in the Balanced cohort, yielding disparities of 27.5% and 22.0%, respectively. The model-adjusted monitorability disparity between cohorts for a given muscle MEP ranged from 0.2% to 16.6% but was smallest for distal intrinsic hand and foot muscle MEPs (0.2%-1.1%) and was largest for proximal muscle MEPs (deltoid: 10.8%, biceps brachii: 8.8%, triceps: 13.0%, quadriceps: 16.6%, gastrocnemius: 7.8%, and tibialis anterior: 3.7%) where the monitorability was significantly decreased in the Balanced cohort relative to the TIVA cohort (p<.0001). Relative to the TIVA cohort, the model-adjusted amplitude of an MEP in the Balanced cohort was smaller for all muscles measured, ranging from 27.5% to 78.0% smaller. Relative to the TIVA cohort, the model-adjusted amplitude of an MEP was significantly decreased (p<.01) in the Balanced cohort for the most proximal muscles (Percent smaller: deltoid: 74.3%, biceps: 78.0%, triceps: 54.9%, quadriceps: 54.8%).

CONCLUSIONS

TIVA is the preferred anesthetic regimen for optimizing MEP monitoring during spine surgery. Inhalational agents significantly decrease MEP monitorability and amplitudes for most muscles, and this effect is especially pronounced for proximal limb muscles such as the deltoid, biceps, triceps, and quadriceps.

Intraperitoneal co-administration of low dose urethane with xylazine and ketamine for extended duration of surgical anesthesia in rats

Procedures involving complex surgical techniques in rats, such as placement of abdominal aortic graft require extended duration of surgical anesthesia, which often can be achieved by repeated administrations of xylazine-ketamine combination. However such repeated anesthetic administration, in addition to being technically challenging, may be associated with potential adverse events due to cumulative effects of anesthesia. We report here the feasibility of using urethane at low dose (~1/10 the recommended anesthetic dose) in combination with a xylazine-ketamine mix to achieve an extended duration of surgical anesthesia in rats. The anesthesia induction phase was quick and smooth with an optimal phase of surgical anesthesia achieved for up to 90 minutes, which was significantly higher compared to that achieved with use of only xylazine-ketamine combination. The rectal temperature, heart rate and respiratory rate were within the physiological range with an uneventful recovery phase. Post surgery the rats were followed up to 3 months without any evidence of tumor or any other adverse effects related to the use of the urethane anesthetic combination. We conclude that low dose urethane can be effectively used in combination with xylazine and ketamine to achieve extended duration of surgical anesthesia up to 90 minutes in rats.

Considerations for the use of short-acting opioids in general anesthesia

Anesthesiologists play a critical role in facilitating a positive perioperative experience and early recovery for patients. Depending on the kind of procedure or surgery, a wide variety of agents and techniques are currently available to anesthesiologists to administer safe and efficacious anesthesia. Notably, the fast-track or ambulatory surgery environment requires the use of agents that enable rapid induction, maintenance, and emergence combined with minimal adverse effects. Short-acting opioids demonstrate a safe and rapid onset/offset of effect; that short effect is both predictable and precise. It also ensures easier titration and reduced or rapidly reversed side effects. Due to their distinct pharmacokinetic and pharmacodynamic properties, and, in one case, rapid extra-hepatic clearance of remifentanil, these agents have several applications in general anesthesia.

[Do anesthetic techniques influence postoperative outcomes? Part II]

The knowledge of the influence of anesthetic techniques in postoperative outcomes has opened a large field of research in recent years. In this second part, we review some of the major controversies arising from the literature on the impact of anesthetic techniques on postoperative outcomes in 6 areas: postoperative cognitive dysfunction, chronic postoperative pain, cancer recurrence, postoperative nausea/vomiting, surgical outcomes, and resources utilization. The development of protective and preventive anesthetic strategies against short and long-term postoperative complications will probably occupy an important role in our daily anesthetic practice. Dynamic postoperative pain control has been confirmed as one of the basic requirements of accelerated postoperative recovery programs ("fast-track surgery"), and it is also a preventive factor for development of chronic postoperative pain. The weight of anesthetic technique on postoperative immunosuppression is to be defined. The potential influence of anesthesia on cancer recurrence, is a highly controversial area of research. The classic pattern of perioperative fluid therapy may increase postoperative complications. On the other hand, the maintenance of normoglycemia and normothermia was associated with a decreased postoperative morbidity. The high volume of surgical procedures means that the adequacy of human, organizational and technological resources have a major impact on overall costs.

A Randomized Controlled Trial of Two Different Interventions for the Prevention of Postoperative Nausea and Vomiting: Total Intravenous Anaesthesia using Propofol and Remifentanil versus Prophylactic Palonosetron with Inhalational Anaesthesia using Sevoflurane-Nitrous Oxide

Total intravenous anaesthesia (TIVA) can reduce the risk of postoperative nausea and vomiting (PONV) almost as much as a single antiemetic. This study compared TIVA (using propofol and remifentanil) with prophylactic palonosetron (a 5-hydroxytryptamine type 3 receptor antagonist) combined with inhalation anaesthesia using sevoflurane in 50% nitrous oxide, for the prevention of PONV. Patients were randomly assigned to one of two prophylactic interventions: (i) palonosetron 0.075 mg, intravenously before induction of inhalation anaesthesia (palonosetron group); and (ii) TIVA (propofol target blood concentration 2.5-6.0 μg/ml; remifentanil target blood concentration 2.5-6.0 ng/ml; TIVA group). Nausea/vomiting occurrence and severity were monitored immediately after the end of surgery for 24 h. The incidence of PONV was around 50% in both groups and the severity of nausea was similar in both groups. Prophylactic palonosetron with inhalational anaesthesia using sevoflurane in 50% nitrous oxide reduced the incidence of PONV after gynaecological laparoscopic surgery almost as much as TIVA using propofol and remifentanil.