[Total intravenous anesthesia in thoracotomy with one-lung ventilation]. A comparison of the effects of propofol-alfentanil versus isoflurane anesthesia on arterial oxygenation during one-lung ventilation. A prospective randomised trial comparing spinal anaesthesia using hyperbaric cinchocaine with general anaesthesia for lower limb vascular surgery. A randomized controlled trial comparing an intraoperative goal-directed strategy with routine clinical practice in patients undergoing peripheral arterial surgery. Prospective randomized clinical trial comparing nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic surgery. Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. The effect of an alveolar recruitment strategy on oxygenation during laparascopic cholecystectomy. [A comparison of enflurane and propofol in thoracic surgery]. Combined epidural and general anaesthesia versus general anaesthesia for abdominal aortic surgery: a prospective randomised trial.
The aim of this study was to evaluate the benefits of total intravenous anaesthesia (TIVA), with the administration of drugs intravenously and the maintenance of pulmonary ventilation with oxygen enriched air, with respect to inhalatory anaesthesia, in thoracotomies with single lung ventilation.
                The study, devoloped in collaboration between the Service of Anaesthesia and Resuscitation and the Division of Thoracic Surgery of the Hospital of Teramo, was carried out in two groups of patients chosen at random; fifty patients divided into two groups of twenty-five were studied. Pre-medication and induction was similar in both groups; maintenance, however, varied: a total intravenous anaesthesia was given to patients in group A whereas patients in group B received an inhalatory anaesthesia. These parameters were considered: pressure values, heartbeat, PaO2 and PaCO2 levels, SatO2 and EtCO2.
                Both protocols respected anaesthetic guidelines in terms of controlling pressure values, heartbeat and levels of PaCO2 during bipulmonary ventilation. Significantly statistical differences were observed in the oxygenation during one lung ventilation: the mean values of PaO2 being significantly higher in group A.
                On the basis of this experience, it can be conclude that TIVA offers the following advantages: a better oxygenation during one lung ventilation, good recovery of post operative consciousness with no psychomotor disturbances, absence of pollution in the operating theatre. To determine whether intravenous propofol-alfentanil anesthesia provides superior arterial oxygenation (Pao2) during one-lung ventilation (OLV) compared with isoflurane inhalation anesthesia.
                A prospective, randomized, cross-over study.
                Tertiary-care university hospital.
                Thirty adults having either thoracoscopic pulmonary surgery or esophageal surgery.
                Patients received either propofol-alfentanil infusion anesthesia or one minimum alveolar concentration (MAC) of isoflurane during the initial period of two-lung ventilation and the first 30 minutes of OLV and then were switched to the other anesthetic for the duration of OLV.
                Arterial blood gases and hemodynamics were recorded during two-lung ventilation and after 20 and 30 minutes of OLV with each anesthetic technique. The mean values (+/- SD) for Pao2 during propofol-alfentanil anesthesia after 20 minutes (222 +/- 100) and 30 minutes (228 +/- 102 mmHg) of one-lung ventilation were not significantly different than after 20 minutes (213 +/- 99) or 30 minutes (214 +/- 96 mmHg) of isoflurane; beta error less than 0.1. Mean heart rate was lower during intravenous (78 +/- 15 min) than inhalation (85 +/- 17 min) anesthesia (rho = 0.03).
                This study does not support the theory that total intravenous anesthesia will decrease the risk of hypoxemia during OLV. One hundred and one patients were randomly allocated to have their peripheral vascular surgery performed under general anaesthesia (51 patients) or spinal anaesthesia (50 patients). Intraoperative haemodynamic changes were markedly different between the two groups with a higher incidence of hypotension in the spinal group (72% vs 31%) and a higher incidence of hypertension in the general anaesthesia group (22% vs 0%). Blood loss was significantly less in the spinal group (560, SD 340, ml vs 792, SD 440, ml). Postoperatively three patients from the general anaesthesia group died from causes unrelated to the anaesthesia, and one had a myocardial infarct. Two patients in the spinal group had myocardial infarcts, both had been treated for bradycardia and hypotension intraoperatively, and one died. There was a significantly higher incidence of postoperative chest infection in the general anaesthesia group (33% vs 16%). There was no significant difference between the groups in the incidence of postoperative confusion, or lower limb amputation rate or need for further surgery prior to hospital discharge. 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. Recent publications demonstrating the safety and advantages of N2O for pneumoperitoneum (PP) prompted us to reconsider N2O as an agent for PP in general surgical laparoscopy. The purpose of this prospective, double-blind, randomized clinical trial was to determine whether N2O PP has any benefits over CO2 PP.
                One hundred three patients received N2O (group I, n = 52) or CO2 (group II, n = 51) PP for elective laparoscopic surgery. Heart rate, mean arterial blood pressure, end-tidal CO2, minute ventilation, and O2 saturation were recorded before PP, during PP, and in the recovery room. Postoperative pain medication use was recorded. Pain was assessed by means of visual analog scale (VAS) at postoperative hours 2 and 4, and on day 1.
                There were no differences between groups I and II in patient age, gender, weight, anesthesia risk (American Society of Anesthesiologists Score > 2), operative time, duration of PP, or length of hospital stay. Mean end-tidal CO2 increase under anesthesia was greater in group II than group I (3.0 versus 0.5 mmHg, p < 0.001) despite a greater mean intraoperative increase in minute ventilation in group II than group I (0.7 versus -0.2 L/min p < 0.001). The patients who had N2O PP had less pain 2 hours postoperatively (VAS: 4.9 versus 5.7, p <0.05), 4 hours postoperatively (VAS: 3.3 versus 5.1, p < 0.01), and 1 day postoperatively (VAS: 1.7 versus 3.5, p < 0.01) than patients who had CO2 PP. Postoperative narcotic or ketorolac use was not statistically different between groups. There were no adverse events related to either N2O or CO2 pneumoperitoneum.
                These results suggest that the use of N2O PP has sufficient advantages over CO2 that it should be considered as the standard agent for therapeutic PP. Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta.
                One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones.
                Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups.
                In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia. This prospective randomized controlled trial examined the effect of an "alveolar recruitment strategy" (ARS) in healthy patients having laparoscopic cholecystectomy. Twenty-four consecutive ASA 1 or 2 patients were randomly allocated to an ARS or control group. All patients were manually ventilated to a maximal airway pressure of 25 to 30 cmH2O or a tidal volume of 10 ml/kg during induction of general anaesthesia. After intubation, the control group was ventilated with standardized mechanical ventilation settings. The ARS group was manually ventilated to an airway pressure of 40 cmH2O for 10 breaths over one minute, followed by mechanical ventilation with similar standardized settings plus 5 cmH2O positive end-expiratory pressure. Blood pressure, heart rate, arterial oxygen and carbon dioxide tension (PaO2 and PaCO2) was measured pre-induction, 20 minutes post induction but before abdominal insufflation, 20 minutes after abdominal insufflation, and 20 minutes after arrival in the recovery room. Demographic and operation data were similar. The ARS group pre-insufflation PaO2 [30.16 (9.43)] was higher than the control group [22.19 (9.08)] (P = 0.047). There was a significant difference in PaO2 between the ARS [23.94 (4.87)] and control [17.26 (3.93)] groups during the post-insufflation period (P = 0.001). There were no significant differences in PaO2 between the groups during baseline and recovery periods. No adverse effects were reported. ARS improved arterial oxygenation intraoperatively in healthy patients having laparoscopic cholecystectomy, without clinical cardiovascular compromise or respiratory complication. We conclude that this alveolar recruitment strategy is a useful method of increasing arterial oxygenation. Comparisons between propofol and inhalational anesthetics for maintenance of anesthesia are limited. The purpose of our prospective study was to examine differences between enflurane and propofol during pulmonary resections with one-lung ventilation (1LV). METHOD. 28 patients, ASA risk group II-III, gave written informed consent for inclusion in this institutionally approved study. The patients were randomly allocated to one of the following groups: A: propofol 10 mg kg-1 h-1, B: 1 MAC enflurane, for maintenance of anesthesia. In both groups analgesia was achieved by fentanyl and muscle relaxation, by pancuronium. Ventilation via a double-lumen tube was controlled (FiO2 = 1.0, PaCO2 35-40 mmHg). Measurements, including hemodynamics and arterial and mixed venous blood gases, were obtained before induction (I), during two-lung ventilation (2LV) 15 min after induction in the supine position (II) and 20 min after surgical opening of the chest in the lateral decubitus position (III), 20 min after starting 1LV (IV), and after extubation (V). RESULTS. No significant differences between the two groups were found before induction (I), during 2LV (II, III), or after extubation (V). The only significant differences between the two groups were observed during 1LV (IV): the shunt fraction was 33.9 +/- 2.5% in A and 38.5 +/- 2.6% in B (P less than or equal to 0.05). Hypoxic pulmonary vasoconstriction was not inhibited in A, but was inhibited by 21.5% in group B during 1LV. Since no case of hypoxemia occurred in group A during 1LV (range of PaO2: 75.2-417.0 mmHg), but four patients developed hypoxemia in group B (Range of PaO2: 46.6-431.0 mmHg), regimen A might be of value in high-risk patients during thoracic surgery when 1LV is planned. Fifty patients undergoing elective abdominal aortic surgery were randomised to receive either combined epidural and general anaesthesia and postoperative epidural analgesia (CEGA) or general anaesthesia and postoperative intravenous morphine infusion (GA). Prospective data was collected in order to compare the two groups. This included intraoperative cardiovascular changes and postoperative complications. The use of intraoperative vasopressors was significantly higher in the CEGA group (P < 0.01) but the use of intravenous glyceryl trinitrate was significantly lower (P < 0.01). There was no significant difference between groups in regard to blood loss, volume replacement or in the number of patients requiring postoperative ventilation. Two patients in the CEGA group died postoperatively compared to one in the GA group (not significant). There was no significant difference between groups in the total number or type of postoperative complications. Combining epidural anaesthesia with general anaesthesia altered intraoperative cardiovascular management but did not affect postoperative outcome.
There is no evidence from randomized controlled trials of differences in patient outcomes for anaesthesia maintained by intravenous versus inhalational anaesthesia during one-lung ventilation. This review highlights the need for continued research into the use of intravenous versus inhalation anaesthesia for one-lung ventilation. Future trials should have standardized outcome measures such as death, adverse postoperative outcomes and intraoperative awareness. Dropouts and losses to follow up should be reported.