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Background Improving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety. Methods A multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia. Discussion Given the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments. Trial registration ISRCTN62903453. September 09, 2021.

Background Vascular endothelial growth factor (VEGF) and transforming growth factor-β (TGF-β) have been involved in tumor growth and metastasis. Sevoflurane may promote angiogenesis, whereas propofol can present an anti-angiogenic effect. In this study, we compared the effects of propofol/remifentanil-based total intravenous anesthesia (TIVA) and sevoflurane-based inhalational anesthesia on the release of VEGF-C and TGF-β, as well as recurrence- free survival (RFS) rates in the patients undergoing breast cancer surgery. Methods Eighty female patients undergoing breast cancer resection were enrolled and randomized to receive either sevoflurane-based inhalational anesthesia (SEV group) or propofol/remifentanil-based TIVA (TIVA group). The serum concentrations of VEGF-C and TGF-β before and 24 h after surgery were measured and RFS rates over a two-year follow-up were analyzed in both groups. The postoperative pain scores assessed using a visual analogue scale (VAS) and the use of perioperative opioids were also evaluated. Results Although VAS scores at 2 h and 24 h after surgery were comparable between the two groups, there were more patients receiving postoperative fentanyl in the TIVA group (16[40%]) compared with the SEV group (6[15%], p  = 0.023). VEGF-C serum concentrations increased after surgery from 105 (87–193) pg/ml to174 (111–281) pg/ml in the SEV group ( P  = 0.009), but remained almost unchanged in the TIVA group with 134 (80–205) pg/ml vs.140(92–250) pg/ml( P  = 0.402). The preoperative to postoperative change for VEGF-C of the SEV group (50 pg/ml) was significantly higher than that of the TIVA group (12 pg/ml) with a difference of 46 (− 11–113) pg/ml ( P  = 0.008). There were also no significant differences in the preoperative and postoperative TGF-β concentrations between the two groups. The two-year RFS rates were 78% and 95% in the SEV and TIVA groups ( P  = 0.221), respectively. Conclusion In comparison with sevoflurane-based inhalational anesthesia, propofol/remifentanil -based total intravenous anesthesia can effectively inhibit the release of VEGF-C induced by breast surgery, but didn’t seem to be beneficial in the short-term recurrence rate of breast cancer. Trial registration Chictr.org.cn ChiCTR1800017910 . Retrospectively Registered (Date of registration: August 20, 2018).

Brain tumors and craniotomy surgeries can induce both systemic and neuronal inflammation. Currently, there is a limited amount of literature addressing the influence of anesthetic agents on neuronal and systemic inflammation in neurosurgical settings and its impact on the occurrence of postoperative neurocognitive dysfunction (PND). Our primary objective is to assess the effects of propofol-based total intravenous anesthesia (TIVA) compared to sevoflurane inhalational anesthesia (INHA) with respect to the levels of perioperative inflammatory markers, specifically neuron-specific enolase (NSE) and interleukin-6 (IL-6) in patients undergoing craniotomy for supratentorial tumor surgery. Our secondary objective is to evaluate the correlation of neuronal, systemic inflammatory markers, and the incidence of PND and functional outcomes in patients receiving TIVA versus INHA for supratentorial tumor surgeries. This study protocol details the methodology of a prospective, randomized, and single-center trial approved by the Institutional Ethics Committee and registered with the Clinical Trial Registry of India. The study focuses on patients undergoing craniotomy for supratentorial glioma decompression. Assessing changes in the biomarker level is the primary objective and correlation of this change in biomarker with PND and functional outcome is our secondary objective. The sample size of 45 patients in each group was calculated using n master software by considering alpha of 5%, power of 80%, a mean difference of 79.2 between the groups, and an effect size of 0.603. We describe the study protocol of the single-center trial. The first patient was recruited on September 17, 2023, and we will complete recruitment before March 2025. Our study is expected to inform the impact of anesthesia technique on the biomarkers of the inflammation and consequently PND. Knowledge about this will help the anesthesiologist to select the appropriate anesthetic drug in their clinical practice.

Laparoscopic sleeve gastrectomy is commonly performed under total intravenous anaesthesia (TIVA) or balanced anaesthesia using an intravenous and inhalation agent. It is still unclear which anaesthesia regimen is better for this group of patients. The present study has been conducted to compare the use of the inhalation anaesthesia technique using desflurane with the TIVA technique, using propofol and dexmedetomidine. Prospective, randomised, double-blinded study. Menoufia Univeristy Hospital. This randomised trial was carried out on 100 morbidly obese patients undergoing laparoscopic sleeve gastrectomy. The patients were randomised into two equally sized groups; one group received the inhalation anaesthesia technique and the other received the TIVA technique. All patients received general anaesthesia, which was induced by propofol, remifentanil, and rocuronium. Anaesthesia was maintained using desflurane in oxygen air mixture in the inhalation group, whilst anaesthesia was maintained by intravenous infusion of propofol and dexmedetomidine in the TIVA group. Intra-operative vital signs, anaesthesia recovery time, postoperative nausea and vomiting, pain score, post-anaesthetic care unit (PACU) stay time, total first 24h post-operative analgesic needs and the onset of first bowel movement were recorded. Main results The TIVA group had lower intra-operative heart rates and mean arterial blood pressure (P<0.0001). The TIVA group also had a lower post-operative visual analogue score for pain assessment (VAS) (P<0.0001), lower total analgesic requirements (P<0.0001), a lower incidence of nausea (P=0.01) and vomiting (P=0.03), and shorter PACU stays (P=0.01). There was no significant difference between groups with regard to the onset of bowel movement (P=0.16). TIVA using propofol and dexmedetomidine is a better anaesthetic regimen than inhalation anaesthesia using desflurane for laparoscopic sleeve gastrectomy in morbidly obese patients. The TIVA technique provided better postoperative recovery with fewer postoperative side effects and analgesic requirements. NCT03029715. •TIVA using propofol and dexmedetomidine is a safe anaesthetic technique for morbidly obese undergoing sleeve gastrectomy.•TIVA technique can maintain a stable intraoperative haemodynamics.•TIVA can provide better postoperative recovery with fewer postoperative side effects and analgesic requirements.

PurposeNew-generation anesthesia machines administer inhalation anesthetics and automatically control the fresh gas flow (FGF) rate. This study compared the administration of minimal flow anesthesia (MFA) using the automatically controlled anesthesia (ACA) module of the Mindray A9 (Shenzhen, China) anesthesia machine versus manual control by an anesthesiologist.MethodsWe randomly divided 76 patients undergoing gynecological surgery into an ACA group (Group ACA) and a manually controlled anesthesia group (Group MCA). In Group MCA, induction was performed with a mixture of 40–60% O2 and air with a 4 L/min FGF until the minimum alveolar concentration (MAC) reached 1. Next, MFA was initiated with 0.5 L/min FGF. The target fraction of inspired oxygen (FiO2) value was 35–40%. In Group ACA, the MAC was defined as 1, and the FiO2 was adjusted to 35%. Depth of anesthesia, anesthetic agent (AA) consumption, time to achieve target end-tidal AA concentration, awakening times, and number of ventilator adjustments were analyzed.ResultsThe two groups showed no statistically significant differences in depth of anesthesia or AA consumption (Group ACA: 19.1 ± 4.9 ml; Group MCA: 17.2 ± 4.5; p-value = 0.076). The ACA mode achieved the MAC target of 1 significantly faster (Group ACA: 218 ± 51 s; Group MCA: 314 ± 169 s). The number of vaporizer adjustments was 15 in the ACA group and 217 in the MCA group.ConclusionThe ACA mode was more advantageous than the MCA mode, reaching target AA concentrations faster and requiring fewer adjustments to achieve a constant depth of anesthesia.

Background Diabetes mellitus is a prevalent metabolic disease in the world. Previous studies have shown that anesthetics can affect perioperative blood glucose levels which related to adverse clinical outcomes. Few studies have explored the choice of general anesthetic protocol on perioperative glucose metabolism in diabetes patients. We aimed to compare total intravenous anesthesia (TIVA) with total inhalation anesthesia (TIHA) on blood glucose level and complications in type 2 diabetic patients undergoing general surgery. Methods In this double-blind controlled trial, 116 type 2 diabetic patients scheduled for general surgery were randomly assigned to either the TIVA group or TIHA group (n = 56 and n = 60, respectively). The blood glucose level at different time points were measured and analyzed by the repeated-measures analysis of variance. The serum insulin and cortisol levels were measured and analyzed with t-test. The incidence of complications was followed up and analyzed with chi-square test or Fisher’s exact test as appropriate. The risk factors for complications were analyzed using the logistic stepwise regression. Results The blood glucose levels were higher in TIHA group than that in TIVA group at the time points of extubation, 1 and 2 h after the operation, 1 and 2 days after the operation, and were significantly higher at 1 day after the operation (10.4 ± 2.8 vs. 8.1 ± 2.1 mmol/L; P  < 0.01). The postoperative insulin level was higher in TIVA group than that in TIHA group (8.9 ± 2.9 vs. 7.6 ± 2.4 IU/mL; P  = 0.011). The postoperative cortisol level was higher in TIHA group than that in TIVA group (15.3 ± 4.8 vs. 12.2 ± 8.9 ug/dL ; P  = 0.031). No significant difference regarding the incidence of complications between the two groups was found based on the current samples. Blood glucose level on postoperative day 1 was a risk factor for postoperative complications (OR: 1.779, 95%CI: 1.009 ~ 3.138). Conclusions TIVA has less impact on perioperative blood glucose level and a better inhibition of cortisol release in type 2 diabetic patients compared to TIHA. A future large trial may be conducted to find the difference of complications between the two groups. Trial registration The protocol registered on the Chinese Clinical Trials Registry on 20/01/2020 (ChiCTR2000029247).

Background and Objectives: Perioperative hyperglycemia is associated with increased risks of infection and mortality. Patients with type 2 diabetes mellitus (T2DM) exhibit variable glycemic responses to surgical stress, highlighting the importance of optimal perioperative glucose control. The aim of this study is to conduct a systematic review and meta-analysis comparing the effects of intravenous versus inhalation anesthesia on perioperative blood glucose levels in patients with T2DM undergoing surgery. Materials and Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized studies identified from Medline, EMBASE, CENTRAL, and Google databases up to 24 October 2024. Eligible studies included adult surgical patients with type 2 diabetes mellitus. Two investigators independently screened studies, extracted data, and assessed methodological quality using the GRADE approach. Results: Five studies (3 RCTs and 2 non-RCTs) involving a total of 512 participants were included. Intraoperatively, inhalation anesthesia was associated with significantly higher blood glucose levels compared to intravenous anesthesia (mean difference [MD]: 12.52 mg/dL; 95% confidence interval [CI]: 0.70–24.35) in the overall analysis. However, subgroup analysis by study design showed no significant differences. Postoperatively, inhalation anesthesia resulted in significantly higher glucose levels than intravenous anesthesia, both in the overall analysis (MD: 23.56 mg/dL; 95% CI: 3.65–43.48) and in RCTs alone (MD: 28.20 mg/dL; 95% CI: 3.67–52.73). Conclusions: Intravenous anesthesia is associated with lower perioperative blood glucose levels compared to inhalation anesthesia, both during and after surgery. Although the effect was not consistently significant across all subgroups, these findings suggest a potential advantage of intravenous anesthesia in patients with T2DM and warrant validation in larger randomized trials.

ObjectivesMyocardial revascularisation and cardiopulmonary bypass (CPB) can cause ischaemia-reperfusion injury, leading to myocardial and other end-organ damage. Volatile anaesthetics protect the myocardium in experimental studies. However, there is uncertainty about whether this translates into clinical benefits because of the coadministration of propofol and its detrimental effects, restricting myocardial protective processes.MethodsIn this single-blinded, parallel-group randomised controlled feasibility trial, higher-risk patients undergoing elective coronary artery bypass graft (CABG) surgery with an additive European System for Cardiac Operative Risk Evaluation ≥5 were randomised to receive either propofol or total inhalational anaesthesia as single agents for maintenance of anaesthesia. The primary outcome was the feasibility of recruiting and randomising 50 patients across two cardiac surgical centres, and secondary outcomes included the feasibility of collecting the planned perioperative data, clinically relevant outcomes and assessments of effective patient identification, screening and recruitment.ResultsAll 50 patients were recruited within 11 months in two centres, allowing for a 13-month hiatus in recruitment due to the COVID-19 pandemic. Overall, 50/108 (46%) of eligible patients were recruited. One patient withdrew before surgery and one patient did not undergo surgery. All but one completed in-hospital and 30-day follow-up.ConclusionsIt is feasible to recruit and randomise higher-risk patients undergoing CABG surgery to a study comparing total inhalational and propofol anaesthesia in a timely manner and with high acceptance and completion rates.Trial registration numberNCT04039854.

The aim of the present study was to assess the quality of recovery from anesthesia of patients subjected to otorhinolaryngological (ORL) surgery under balanced or total intravenous general anesthesia by means of Quality of Recovery-40 (QoR-40) questionnaire. Prospective randomized clinical trial. The setting is at an operating room, a postoperative recovery area, and a hospital ward. One-hundred thirty American Society of Anesthesiologists physical status I or II patients scheduled to undergo general anesthesia for ORL interventions under remifentanil, in combination with sevoflurane (balanced technique) or propofol (total intravenous anesthesia). Occurrence of nausea, vomiting, body temperature less than 36°C, and length of stay in the postanesthesia care unit were recorded. The QoR-40 was administered by an investigator blind to group allocation 24 hours after surgery. The quality of recovery, as assessed by the score on the QoR-40, was compared between the groups. There is no difference regarding the QoR-40 score among intravenous and inhalation anesthesia groups (190.5 vs 189.5, respectively; P=.33). Similarly, among the 5 dimensions of the QoR-40, the scores were comparable between the groups. Incidence of hypothermia (P=.58), nauseas or vomits (P=.39), and length of surgery (P=.16) were similar among groups. The evaluation of pain intensity (P=.80) and dose of morphine use in the postanesthesia care unit (P=.4) was also comparable between groups. The quality of recovery from anesthesia assessed based on the patients' perception did not differ between the ones subjected to either inhalation or intravenous general anesthesia for ORL surgery based on QoR-40 questionnaire assessment. •Both intravenous and inhalation anesthesia exhibit specific individual advantages.•We assessed the quality of recovery (QoR-40) from both techniques.•Recovery from remifentanil/sevoflurane or remifentanil/propofol was compared.•The lack of difference was demonstrated on the total QoR-40 score.

Introduction The study aimed to compare anesthesia maintenance using total intravenous anesthesia (TIVA) and inhalation anesthesia (IA) and investigating their effects on bleeding volume, intraoperative hemodynamic changes, and postoperative complications in women patients undergoing abdominal myomectomy. Methods A double-blind randomized controlled trial was conducted on patients undergoing abdominal myomectomy at a large non-university hospital in northwest Iran in 2023. A total of 60 eligible patients were randomly assigned to two groups of TIVA ( n  = 30) and IA ( n  = 30) anesthesia methods. The study groups’ allocation was blinded to the anesthesiology provider and she was responsible for anesthesia and patient monitoring. The study outcomes were hemodynamic changes, bleeding during the surgery, anesthesia time, hospitalization, and postoperative complications between the study groups. Results There were no significant differences in surgical indications, myoma size, hemoglobin levels, or clinical and obstetric characteristics before surgery between the two study groups ( p  > 0.05). The average blood loss (201.8 vs. 391.0 ml; P  = 0.001), postoperative hemoglobin levels (11.6 vs. 10.5; P  = 0.005), anesthesia times (100.6 vs. 114.3 min; P  = 0.003), and hospitalization days (2.06 vs. 2.36; P  = 0.005) showed statistically significant differences between the TIVA and IA groups, respectively. Mean arterial pressure (MAP) and heart rate values were significantly higher in the IA group compared to the TIVA group ( P  < 0.05). No muscle stiffness, dizziness, or respiratory depression were observed after surgery in either study group. The proportion of shivering in the TIVA and IA groups was 16.7% and 43.3%, respectively, indicating a significant statistical difference ( P  = 0.024). The proportion of optimal surgeon performance was reported to be higher in the TIVA group compared to the IA group ( P  = 0.014). Conclusion According to the findings of this study, the use of the TIVA method compared to IA during the maintenance of general anesthesia was linked to a reduction in intraoperative bleeding and transfusion requirements, as well as increased optimal surgeon performance in patients undergoing abdominal myomectomy. Furthermore, patients in the TIVA group experienced fewer complications during and after surgery, along with a shorter hospital stay. Trial registration The study protocol was retrospectively registered and confirmed in the Iranian Registry of Clinical Trials under the number (IRCT20220930056059N1). Registration date: 2022-11-13. Expected recruitment start date: 2022-11-11.