Perioperative ERAS Approach

Defining The Role of Desflurane in

Multifarious Patients & Surgeries
Dr Omar Hj Sulaiman
Hospital Sultanah Aminah Johor Bahru,Johor
 Emphasis on
cost
Emphasis on containment
evidence-
based
practice

Rising
patient
expectations

Changes In Health Care

Delivery

Improving Perioperative Patient Safety: A Matter of Priorities, Collaboration and Advocacy : Mark A. Warner, MD APSF President. APSF Newsletter February 2021

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Enhanced Recovery After
Surgery
Multidiscipline
Approach

Improved
System- Evidence Based
Centered Practice
Outcome

Improved
Patient- Standardization
Centered Protocol
Outcome

Guidelines for Perioperative Care for ERAS: European ERAS Society 2020

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ERAS :Cycle of diffusion & continuous
improvement
Discovery Application

Translation

Hypothesis
Review of past
experience

Assess
Impact Trial
National Individual or
database small gp Ix

Regional
National Local change
Diffusion Adoption of
outside practice
organization

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Perioperative Care ERAS : Latest Update European ERAS Society 2020

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 Nelson G, Kiyang L, Crumley E, et al. Implementation of
Enhanced Recovery After Surgery (eras) across a provincial
healthcare system: the eras Alberta colorectal surgery experience.
World J Surg 2016;40:1092–103.

Procedure Specific
Best Practices
ERAS

Decrease the Reduce health care

incidence & severity Shorten hospital Reduce postop Allow early return costs without
of perioperative length of stay readmission rates to daily living compromising
complications patient care

Lau CS, Chamberlain RS (2017) Lee L, Mata J, Ghitulescu GA, et al.

Enhanced recovery after surgery Cost-effectiveness of ERAS versus
programs improve patient conventional perioperative
outcomes and recovery: a meta- management for colorectal surgery.
analysis. World J Surg 41:899–913 Ann Surg 2015;262:1026–33

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History………
Henrik Kehlet, M.D., Ph.D., Recipient of the 2014
Excellence in Research Award
DR. Henrik Kehlet is perhaps the most well-known surgeon
among anesthesiologists around the world due to his
substantial contributions toward the understanding of
surgical pathophysiology

From Surgical Stress Response to Multimodal Analgesia, 1980s

Pre-emptive Analgesia and Transition
from Acute to Chronic Pain,1990s

Fast-track Surgery, mid1990s,

PROSPECT Establishing Prospective Patient
ERAS 1995 Databases

Publication July 3, 2014. From the Department of Anesthesia, McGill University, Montreal, Quebec, Canada.

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Evolution…..
The mission of the ERAS Society is to develop perioperative care and to improve
recovery through research, education, audit and implementation of evidence-
based practice
2001Ken Fearon and Olle Ljungqvist met in London at a nutrition
symposia and decided to start a collaborative group on peri-
operative care.
2001-2004
The ERAS® Society has its roots in what was called the
ERAS® Study Group.

2005The ERAS Study Group developed and published an evidence-based consensus

protocol for patients undergoing colonic surgery

2011The 1st National symposium supported by the

ERAS® Society, held in San Raffaele hospital in Milano
Italy June 17, 2011.The same year the 1st International
ERAS Implementation symposia was held in Milano

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1st. ERAS ASIA CONGRESS 2019, SINGAPORE

The inaugural ERAS Asia Congress took place over 26-28th September 2019 in
Singapore. Kicking off with a pre-congress workshop and a site visit to Tan Tock Seng
Hospital, an ERAS Centre Of Excellence since 2016, the congress opened to more
than 250 participants from across 17 countries worldwide

ERAS Asia Congress in Manila In

2021

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Multidiscipline Evidence Based Standardization
Approach Approach Protocol

Improved Patient- Improved

Centered System-Centered
Outcome Outcome

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ERAS – Future of Anesthesia Care

Reduces
Reduces complications
cost Pts. safety

Reduces
Reduces variability
length of in
stay outcomes

Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After SurgeryA Review. JAMA Surg. Published online January 11, 2017

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Intraoperative Anaesthesiologist’s Goals:

Triad of Anaesthesia

Maintain Homeostatis

Fast & Smooth

Recovery

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 Rapid &
Smooth
Recovery

Multimodal
Evidence Maintain
Homeostasis
Based
Protocol

Triad of anaesthesia

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 Traditional Recovery – Wake Up

Enhanced Recovery – Long term outcomes

Safe Efficient Predictable

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Maintenance of Anaesthesia…

Inhalational Agents TIVA / TCI

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Inhalational Agents vs TIVA

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 Inhalational
TIVA/TCI
Anaesthesia

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Anaesthetic Gases….
Really?? …. Global
warming &
Greenhouse effect!!!

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Environmental sustainability in anaesthesia and critical care
Forbes McGain, Jane Muret, Cathy Lawson and Jodi D. Sherman Western Health, Footscray, Australia,
French Society of Anaesthesia and Intensive Care (SFAR), Institute Curie PSL Research University,
Paris, France, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, England, UK and Department of
Anesthesiology,Yale School of Medicine, Department of Environmental Health Sciences,Yale School of
Public Health, New Haven, CT, USA.
British Journal of Anaesthesia, 125 (5): 680-692 (2020)

Definitive method used to Carbon footprint of

compare & contrast reusable vs single-use
Life Cycle Assessment
ecological footprints of anaesthetic devices in
(LCA)
products, processes & anaesthetic & critical care
systems services

Anaesthetic Gases???
Consumable Equipments???
Avoid, reduce, reuse, recycle
Reusable Anaesthetic
& reprocess
Equipment???

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Pollution…..???
General Anesthetic Gases and the Global Environment
Ishizawa,Yumiko, MD, MPH, PhD
Anesthesia & Analgesia: January 2015 - Volume 112 - Issue 1 - p 213–217

Compound Ozone Depletion Potential

(ODP)
Nitrous oxide, N2O 0.017

Halothane, CF3CHClBr 0.4

Isoflurane, CF3CHClOCHF2 0.01

Sevoflurane(CH3)2CHOCH2F 0

Desflurane, CF3CHFOCHF2 0

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 WE HAVE THE ABILITY TO REDUCE THE ENVIRONMENTAL
IMPACT OF OUR ANESTHESIA TECHNIQUES AND STRIVE
FOR SUSTAINABILITY
by Bohringer, Christian, MD | June 04, 2019

Propofol infusions are associated with lower greenhouse gas emissions than
volatile anesthetics but they create more medical waste in the form of
syringes, syringe tubing, anti-reflux valves and additional intravenous
catheters that are inserted to administer a total intravenous anesthetic. The
electricity requirements for the pump delivery systems and the carbon
footprint of the manufacture of the infusion pumps also need to be
considered

On environmental grounds, some anaesthetists favour the use of propofol.

However, its breakdown leads to the formation of phenol, which is classified
as ‘2’ on a list ranking from 0 to 3 (0: no environmental damage, 3: the
highest environmental damage). Hence there is an environmental impact of
total intravenous anaesthesia with propofol

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Environmental Sustainability in
Anaesthesia & Critical Care ~ LCA

Anaesthetic
TIVA
Gases

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Desflurane & ERAS ???

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Back to Basic : Inhaled Anesthetics:
Partition Coefficients

Blood:Gas Brain:Blood Fat:Blood Muscle:Blood

Nitrous Oxide 0.47 1.1 2.3 1.2

Desflurane 0.42 1.29 27.2 2.02

Sevoflurane 0.69 1.7 47.5 3.13

Isoflurane 1.43 1.57 44.9 2.92

Yasuda N et al. Anesth Analg. 1989; 69[3]: 370-373

Eger EI et al.Pharmacoeconomics 2000 Mar; 17 (3): 245-262

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 Metabolism

Inhaled Agents % Metabolized

Halothane 15 – 20 %
Enflurane 2%
Isoflurane 0.17%
Desflurane 0.02%
Sevoflurane 5%

Desflurane: * 10 times less metabolized than Isoflurane

* 250 times less metabolized than Sevoflurane
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Recovery to MACawake (0.33 MAC)
Can Be Rapid With All Inhaled Anesthetics
Which is more reliable Airway Reflex recovery or Eye opening?

75

Minutes
to an 80% 50
Decrement in
the VRG
Concentration Isoflurane
25

Sevoflurane

0 Desflurane
0 100 200
Minutes of Anesthesia

Eger EI et al. Anesth Analg. 2005;101:688-696.

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But Recovery to Light Anesthesia May Be Less
Rapid With More Soluble Inhaled Anesthetics

75
Isoflurane
Sevoflurane

Minutes 50
to a 92%
Decrement in
the VRG
Concentration 25 Desflurane

0
0 100 200
Minutes of Anesthesia
Eger EI et al. Anesth Analg. 2005;101:688-696.

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 decreases
sympathetic
stimulation to the
patient.
allows users to Quality Improvement BMJ 2019
achieve Promoting low-flow anaesthesia
and
quick wash-in of volatile anaesthetic agent choice
desflurane on Louise A Carter
induction without Molola Oyewole
excessive waste ~ Eleanor Bates
efficiency Kate Sherratt

“Rule of
24” fresh gas flow (l/ min) multiplied
Desflurane by volume percent of desflurane
must not exceed 24, once the
patients return of spontaneous
ventilation, anesthesiologist turns
on oxygen 1 l/ min, nitrous oxide 1
l/ min, and desflurane 12 vol% for
1-2 minutes. MAC 0.5-1.0

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Meta-analysis of desflurane and propofol average times and variability in
times to extubation and following commands
Ruth E. Wachtel PhD, Franklin Dexter MD, PhD, Richard H. Epstein MD & Johannes Ledolter
PhD
Canadian Anaesthetists Society Journal 58(8):714-24 ·June 2014

The authors reviewed 324 articles, and identified 182 articles that potentially satisfied
inclusion criteria: a) humans assigned randomly to desflurane or propofol groups without
other differences between groups, e.g., induction drugs; b) mean and standard deviation
reported for extubation time and/or time to follow commands; and c) peer-reviewed
publication, i.e., exclusion of letters, editorials, and Meta-analysis to compare the operating
room recovery time of desflurane with that of propofol. Since there was heterogeneity of
variance between treatment groups in the log-scale (i.e., unequal coefficients of variation of
observations in the time scale). Desflurane reduced the variability in time to extubation
by 26% relative to propofol (95% confidence interval [CI], 6% to 42%; P = 0.006) and
reduced the variability in time to follow commands by 39% (95% CI, 25% to 51%; P <
0.001). Desflurane reduced the mean time to extubation by 21% (95% CI, 9% to 32%; P
= 0.001) and reduced the mean time to follow commands by 23% (95% CI, 16% to 30%;
P < 0.001). The mean reduction in operating room recovery time for desflurane relative to
propofol was comparable with that shown previously for desflurane relative to sevoflurane.

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Published online 2016 Oct 25.
Comparison of Anesthesia-Controlled Operating Room Time between
Propofol-Based Total Intravenous Anesthesia and Desflurane Anesthesia
in Open Colorectal Surgery: A Retrospective Study
Wei-Hung Chan,1 Meei-Shyuan Lee,2 Chin Lin,3 Chang-Chieh Wu,4
Hou-Chuan Lai,1 Shun-Ming Chan,1 Chueng-He Lu,1 Chen-Hwan
Cherng,1 and Zhi-Fu Wu1

Conclusions
The results demonstrate that the mean time to extubation in propofol-based
TIVA by TCI is equivalent to desflurane anesthesia in open colorectal
surgery. Prolonged surgical time and age contributed to prolonged extubation in
this study.
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Comparison of maintenance, emergence and recovery characteristics of
sevoflurane and desflurane in pediatric ambulatory surgery
Manish B. Kotwani, Anila D. Malde
Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General
Hospital, Sion, Mumbai, Maharashtra, India
2018 Journal of Anaesthesiology Clinical Pharmacology

Results: Demography, perioperative hemodynamics, and duration of inhalational anesthesia were comparable
between two groups. There were no respiratory adverse events in either group during maintenance. Time to
awakening and time to removal of SGA were shorter with desflurane (5.3 ± 1.4 and 5.8 ± 1.3 min) than
sevoflurane (9.1 ± 2.4 and 10.0 ± 1.6 min) (P < 0.0001).
Recovery (steward recovery score = 6) was faster with desflurane (18 ± 8.4 min) than sevoflurane (45.3 ± 9.7
min) (P < 0.001).
The incidence of EA was 16.7% with desflurane and 10% with sevoflurane (P = 0.226).
Conclusion: Desflurane provides faster emergence and recovery in comparison to sevoflurane
when used for the maintenance of anaesthesia through SGA in children. Both sevoflurane and
desflurane can be safely used in children for lower abdominal surgeries.

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Comparison of recovery profile after ambulatory anesthesia with propofol,
isoflurane, sevoflurane and desflurane: a systematic review
Anil Gupta 1, Tracey Stierer, Rhonda Zuckerman, Neal Sakima, Stephen D Parker
Anesth Analg 2004 Mar; 98 (3): 632-634

Abstract
In this systematic review , focused on postoperative recovery and complications using four different anesthetic
techniques.The database MEDLINE was searched via PubMed (1986to June 2002) using the search words
"anesthesia" and with ambulatory surgical procedures limited to randomized controlled trials in adults (>19
yr), A second search strategy was used combining two of the words "propofol," "isoflurane," "sevoflurane," or
"desflurane". Screening and data extraction produced 58 articles that were included in the final meta-analysis.
No differences were found between propofol and isoflurane in early recovery. However, early recovery was
faster with desflurane compared with propofol and isoflurane . A minor difference was found in home readiness
between sevoflurane and isoflurane (5 min) but not among the other anesthetics. Nausea, vomiting, headache,
and postdischarge nausea and vomiting incidence were in favor of propofol compared with isoflurane (P <
0.05). A larger number of patients in the inhaled anesthesia groups required antiemetics compared with the
propofol group.The incidence of side effects, specifically postoperative nausea and vomiting, was less frequent
with propofol.
Implications: A systematic analysis of the literature comparing postoperative recovery after
propofol, isoflurane, desflurane, and sevoflurane-based anesthesia in adults demonstrated that
early recovery was faster in the desflurane and sevoflurane groups.The incidence of nausea and
vomiting were less frequent with propofol.

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Anesthesia recovery comparison between remifentanil-propofol and
remifentanil-desflurane guided by Bispectral Index® monitoring
Raphael Grossi Rochaa, Eduardo Giarola Almeida, Lara Moreira Mendes Carneiro
Natália Farias de Almeida, Walkíria Wingester Vilas Boas b, Renato Santiago
Gomez
Universidade Federal Minas Gerais (UFMG), Faculdade de Medicina, Centro de
Pós-graduac¸ão, Belo Horizonte, MG, Brazil
REVISTA BRASILEIRA DE ANESTESIOLOGIA 2016

Forty patients were randomly assigned into 2 groups according to the anesthesia technique applied: remifentanil-
propofol (REM-PRO) and remifentanil-desflurane (REM-DES). After the discontinuation of the anesthetics, the
times to extubation, to obey commands and to recover the airway protection reflex were recorded. In the post-
anesthetic recovery room (PACU) it was recorded the occurrence of nausea and vomiting (PONV), scores of
Ramsay sedation scale and of numeric pain scale (NPS), morphine dose and length of stay in the unit.
Results: Data from 38 patients were analyzed: 18 from REM-PRO and 20 from REM-DES group. Anesthesia times
were similar (REM-PRO= 193 min, SD 79.9 vs. 175.7 min, SD 87.9 REM-DES; p = 0.5). REM-DES had shorter
times than REM-PRO group: time to follow command (8.5 min; SD 3.0 vs. 5.6 min; SD 2.5; p = 0.0) and extubation
time (6.2 min; 3.1---8.5 vs. 9.5 min; 4.9---14.4; p = 0.0). Times to recover airway protective reflex were similar: 16
patients from REM-PRO (88.9%) restored the airway protective reflex 2 min after extubation vs. 17 from REM-
DES (89.5%); and 2 patients from REM-PRO (11.1%) vs. 2 from REM-DES (10.5%) 6 min after extubation, p = 1.
Ramsay sedation score, NPS, PONV incidents, morphine dose and PACU stay of length PACU were also similar

Conclusion: Remifentanil-desflurane-based anesthesia has a faster extubation time and

to follow command than remifentanil-propofol-based anesthesia when both guided by
BIS®

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Comparison of the incidence of emergence agitation and emergence
times between desflurane and sevoflurane anesthesia in children : A
systematic review and meta-analysis
Byung Gun Lim, MD, PhD,a Il Ok Lee, MD, PhD,a Hyeongsik Ahn, MD, PhD,b Dong Kyu Lee,
MD, PhD,aYoung Ju Won, MD, PhD,a Hyun Jung Kim, PhD,b,∗ and Heezoo Kim, MD, PhDa,
Medicine (Baltimore) 2016 Sep

The design of the study is a systematic review with meta-analysis of randomized controlled trials. The study
methodology is based on the Cochrane Review Methods. A comprehensive literature search was conducted to
identify clinical trials comparing the incidence or severity of EA and emergence times in children anesthetized
with desflurane or sevoflurane.
Fourteen studies met the inclusion criteria. Among the 1196 patients in these 14 studies, 588 received
desflurane anesthesia and 608 received sevoflurane anesthesia. The incidence of EA was comparable
between the 2 groups (pooled RR = 1.21; 95% CI: 0.96–1.53; I2 = 26%), and so was the severity of EA (EA score)
between the 2 groups (SMD = 0.12; 95% CI: −0.02 to 0.27; I2 = 0%). Extubation and awakening times were
shorter in the desflurane group than in the sevoflurane group; the weighted mean differences were −2.21 (95%
CI: −3.62 to −0.81; I2 = 93%) and −2.74 (95% CI: −3.80 to −1.69; I2 = 85%), respectively. No publication bias was
found in the funnel plot. The subgroup analysis based on the type of EA scale showed a higher incidence of EA in
the desflurane group than in the sevoflurane group in studies using 3-, 4-, or 5-point EA scales; the pooled RR
was 1.38 (95% CI: 1.10–1.73; I2 = 37%).
Conclusion:
The incidence and severity of EA were comparable between desflurane and sevoflurane
anesthesia in children; however, emergence times, including extubation and awakening times, were
shorter in desflurane anesthesia

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 Time to regain pharyngeal reflexes shorter with
Desflurane Than for Sevoflurane

P<0.01Desflurane vs Sevoflurane
30 P<0.05 for BMI ≥30 vs 18-24 for Sevoflurane

Time From 25
Anesthetic
Discontinuation 20
Until First Ability Sevoflurane
to Swallow (T3)
15
(Minutes, Desflurane
Mean±SD)
1000 s = 17 min 10

5 n=20 n=20

0 18–24 25–29 ≥30

* Regarding swallowing: Administering water to patients after BMI (kg m-2)
anesthetic discontinuation is not a standard of care.
McKay RE et al. Br J Anaesth. 2010;104:175-182.
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 Desflurane Recovery is Independent of BMI

Sevoflurane Desflurane
2500 2500
Time (s)
From 2000 2000
Anesthetic
Discontinuation
1500 1500
Until First P=0.02
Ability to P<0.01
Swallow* 1000 1000
(T3) (Seconds)
1000 s = 17 min
500 500 P=0.12
(not
P=0.03 significant)
0 0
15 20 25 30 35 40 45 15 20 25 30 35 40
BMI (kg m–2) BMI (18–35kg m–2)
* Regarding swallowing: Administering water to patients after
McKay RE et al. Br J Anaesth. 2010;104:175-182.
anesthetic discontinuation is not a standard of care.

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Canadian Journal of Anesthesia
August 2017,Volume 62
Postoperative recovery after anesthesia in morbidly obese patients: A
systematic review and meta-analysis of randomized controlled trials
Feng-Lin LiuYih-Giun CherngShin-Yan ChenYen-Hao SuShih-Yu HuangPo-Han
LoYen-Ying LeeKa-Wai TamEmail
Since studies are lacking regarding the postoperative effects on recovery from general anesthesia in morbidly
obese patients, a systematic review and meta-analysis of recovery outcomes in morbidly obese patients who
had undergone general anesthesia were conducted.
Randomized controlled trials that evaluated the outcome of anesthesia with desflurane,
sevoflurane, isoflurane, or propofol in morbidly obese patients. Using a random effects model,
conducted meta-analyses to assess recovery times (eye opening, hand squeezing, tracheal extubation, and
stating name or birth date), time to discharge from the postanesthesia care unit (PACU), and the incidence and
severity of PONV.
Results:
11 trials and found that patients given desflurane took less time: to respond to commands to open their eyes
(weighted mean difference [WMD] −3.10 min; 95% confidence interval (CI): −5.13 to −1.08), to squeeze the
investigator’s hand (WMD −7.83 min; 95% CI: −8.81 to −6.84), to be prepared for tracheal extubation (WMD
−3.88 min; 95% CI: −7.42 to −0.34), and to state their name (WMD −7.15 min; 95% CI: −11.00 to −3.30). We
did not find significant differences in PACU discharge times, PONV, or the PACU analgesic requirement.
Conclusion
Postoperative recovery was significantly faster after desflurane than after sevoflurane, isoflurane,
or propofol anesthesia in obese patients. No clinically relevant differences were observed regarding
PACU discharge time, incidence of PONV, or postoperative pain scores.

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Cost-effectiveness of propofol anesthesia using target-controlled infusion compared
with a standard regimen using desflurane
Patricia O. Fombeur, Pharm.D., Patrick R.Tilleul, Ph.D., Pharm.D., Marc J. Beaussier, M.D.,
Christine Lorente, Ph.D., Pharm.D., LassaadYazid, M.D., André H. Lienhart, Ph.D., M.D.
American Journal of Health-System Pharmacy, Volume 59, Issue 14, 15 July 2002.

Abstract
The cost-effectiveness of propofol anesthesia using target-controlled infusion (TCI) versus a standard
regimen using desflurane for anesthesia maintenance was analyzed. This observational study consisted of
100 inpatients 18 to 75 years old with an American Society of Anesthesiologists physical status of I or II who
were scheduled for otological surgery lasting less than four hours. Patients received one of two treatments. The
desflurane-maintenance group received propofol 2-4 mg/kg and sufentanil 0.15-0.30 microg (as the citrate)/kg.
A constant fresh gas flow of 1 L/min was used during maintenance of anesthesia. The propofol-maintenance
group received TCI propofol and an additional infusion of sufentanil. Anesthesia was induced with 0.15-0.30
microg/kg.The cost of drugs and medical devices used during the intraoperative and postoperative periods was
calculated. Effectiveness was defined as the absence of postoperative nausea and vomiting (PONV), while the
cost-effectiveness of each procedure was the cost per PONV-free episode. Chi-square and t tests, sensitivity
analysis, and logistic regression were also performed. The only intergroup difference detected was the
frequency of PONV occurring in the early recovery phase (11 in the desflurane group versus 2 in the propofol
group). Of those patients requiring antiemetic rescue, 9 were in the desflurane group and only 2 were in the
propofol group (p < 0.05)The TCI propofol regimen was more expensive than the desflurane
regimen ($45 versus $28 per patient, respectively) (p < 0.001). The differential cost-effectiveness
ratio was $94.7 per PONV-free episode. PONV 24 hours after surgery and patient satisfaction
were similar between groups. A standard regimen of desflurane was more cost-effective than TCI
propofol for anesthesia maintenance in achieving PONV-free episodes.

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A comparison of total intravenous anaesthesia using propofol with
sevoflurane or desflurane in ambulatory surgery: systematic
review and meta-analysis
G. Kumar, C. Stendall,R. Mistry,K. Gurusamy and D. Walker
Department of Anaesthesia and Intensive Care, University College London
Hospitals NHS Foundation Trust, London, UK
2014 The Association of Anaesthetists of Great Britain and Ireland

Systematic review and meta-analysis to determine the type of anaesthesia used had any bearing on pts outcomes.
TIVA was compared with sevoflurane and desflurane. In total, 18 trials were identified. A total 1621 patients
were randomly assigned to compared with sevoflurane and desflurane.
Either propofol (685 patients) or inhalational anaesthesia (936 patients).
There was no difference in unplanned admission to hospital between propofol and inhalational agents (1.0% vs
2.9%, p=0.13).The incidence of postoperative nausea and vomiting was lower with propofol than with inhalational
agents (13.8% vs 29.2%, p<0.001).However, no difference was noted in post-discharge nausea and vomiting
(23.9% vs 20.8%, p=0.26). Length of hospital stay was shorter with propofol, but the difference was only 14 min
on average.
The use of propofol was also more expensive, with a mean (95% CI) difference of £6.72 (£5.13–
£8.31 (€8.16
(€6.23 €10.09); $11.29 ($8.62–$13.96) per patient-anaesthetic episode (p < 0.001). Therefore, based
on the published evidence to date, maintenance of anaesthesia using propofol appeared to have no bearing on the
incidence of unplanned admission to hospital and was more expensive, but was associated with a decreased
incidence of early postoperative nausea and vomiting compared with sevoflurane or desflurane in patients
undergoing ambulatory surgery.

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 Perioperative Medicine | January 2019
Total Intravenous Anesthesia versus Inhalation Anesthesia for Breast
Cancer Surgery: A Retrospective Cohort Study
SeokhaYoo, M.D.; Han-Byoel Lee, M.D.; Wonshik Han, M.D., Ph.D.; Dong-
Young Noh, M.D., Ph.D.; Sun-Kyung Park, M.D.; et al

IV anesthesia may impair anticancer immunity less than volatile anesthesia and therefore reduce recurrence risk.
In a large propensity-matched retrospective cohort analysis, the authors compared total IV and volatile anesthesia for breast cancer
surgery Recurrence hazard was similar with each approach Selection of IV or volatile anesthesia should be based on factors other
than cancer recurrence
Methods: January 2005 and December 2013. The patients were grouped according to whether IV or inhalation anesthesia was
used for surgery. Propensity score matching was used to account for differences in baseline characteristics. Kaplan–Meier survival
curves were constructed to evaluate the influence of type of anesthesia on recurrence-free survival and overall survival. The risks of
cancer recurrence and all-cause mortality were compared between each type of anesthesia.
Results: Of 7,678 patients who had breast cancer surgery during the study period, data for 5,331 patients were available for
analysis (IV group, n = 3,085; inhalation group, n = 2,246). After propensity score matching, 1,766 patients remained in each group.
Kaplan–Meier survival curves showed that there was no significant difference in recurrence-free survival or overall survival between
the two groups, with 5-yr recurrence-free survival rates of 93.2% (95% CI, 91.9 to 94.5) in the IV group and 93.8% (95% CI, 92.6 to
95.1) in the inhalation group. Inhalation anesthesia had no significant impact on recurrence-free survival (hazard ratio, 0.96; 95% CI,
0.69 to 1.32; P = 0.782) or overall survival (hazard ratio, 0.96; 95% CI, 0.69 to 1.33, P = 0.805) when compared with total IV
anesthesia.
Conclusions: The authors found no association between type of anesthesia used and the long-term prognosis of
breast cancer. The results of this retrospective cohort study do not suggest specific selection of IV or inhalation anesthesia for
breast cancer surgery.

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Airway reactions and emergence times in general laryngeal mask airway
anaesthesia
A meta-analysis
Ana Stevanovic, Rolf Rossaint, Harald G. Fritz, Gebhard Froeba, Joern Heine,
Friedrich K. Puehringer, Peter H. Tonner and Mark Coburn
Eur J Anaesthesiol 2015; 32:106–116

13 RCTs were included and analysed. There was no difference in the rates of upper airway events between
desflurane and sevoflurane or between desflurane and a control group consisting of all the other anaesthetics
combined. Comparing desflurane (n ¼ 284) with all other anaesthetic groups (n ¼ 313), the risk ratio [95%
confidence interval (95% CI)] was 1.12 (0.63 to 2.02, P ¼ 0.70). Cough at emergence was only measured in
patients receiving desflurane (n ¼ 148) and sevoflurane (n ¼ 146): the risk ratio (95% CI) was 1.49 (0.55 to
4.02, P ¼ 0.43). Laryngospasm was rare and there was no significant difference in its incidence when
desflurane (n ¼ 262) was compared with all other anaesthetics combined (n ¼ 289; risk ratio 1.03; 95% CI
0.33 to 3.20, P ¼ 0.96). The times of all emergence variables were significantly faster in the desflurane group
than in all other groups.
CONCLUSION :When using an LMA, upper airway adverse reactions in association with
desflurane anaesthesia were no different from those noted with sevoflurane, isoflurane or
propofol anaesthesia.
Emergence from general anaesthesia with desflurane is significantly faster than all the other
anaesthetics.

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Occurrence of cough overall (CO) and cough at emergence (CE). (a) CO: Summary risk ratios (RR) for each subgroup shown as subtotals. Summary risk
ratios (RR) for desflurane vs. all other agents shown as total. RR for individual studies = square on Forrest plot, with 95% CI of difference, solid line.
Diamonds, pooled estimate and uncertainty for the combined effect. (b) CE: Summary risk ratios (RR) calculated with random effects method. RR for
individual studies, square on Forrest plot, with 95% CI of difference, solid line. Diamonds, pooled estimate and uncertainty for the combined effect

For Healthcare Professionals Only. MY-PH49-210010 04/21

The occurrence of laryngospasm: desflurane vs. other groups and desflurane vs. sevoflurane. Summary risk ratios (RR)
calculated with random effects method for each subgroup shown as subtotals. Summary risk ratios (RR) calculated with
random effects method for desflurane vs. all other agents shown as total. RR for individual studies, square on Forrest plot,
with 95% CI of difference, solid line. Larger sized square and thicker 95% CI line, larger sample size. Diamonds, pooled
estimate and uncertainty for the combined effect.

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Forrest plot time to open eyes (TOE) and time to remove LMA (TLR). Summary mean difference calculated with random effects method for
each subgroup shown as subtotals. Summary mean difference calculated with random effects method for desflurane vs. all other agents
shown as total. Mean difference for individual studies, square on Forrest plot, with 95% CI of difference, solid line. Diamonds, pooled estimate
and uncertainty for the combined effect. Time is represented in minutes. (a) TOE. (b) TLR

For Healthcare Professionals Only. MY-PH49-210010 04/21

Forrest plot time to respond to command (TRC) and time to state the date of birth (TSB). Summary mean difference calculated with random effects
method for each subgroup shown as subtotals. Summary mean difference calculated with random effects method for desflurane vs. all other agents
shown as total. Mean difference for individual studies, square on Forrest plot, with 95% CI of difference, solid line. Diamonds, pooled estimate and
uncertainty for the combined effect. Time is represented in minutes. (a) TRC. (b) TSB

For Healthcare Professionals Only. MY-PH49-210010 04/21

Effects of Volatile Anesthetics on Mortality and Postoperative Pulmonary and
Other Complications in Patients Undergoing Cardiac Surgery . A Systematic
Review and Meta-analysis
Christopher Uhlig, M.D.,Thomas Bluth, M.D., Kristin Schwarz, M.Sc., Stefanie Deckert, M.Sc., Luise
Heinrich, M.Sc., Stefan De Hert, M.D., Ph.D., Giovanni Landoni, M.D., Ary Serpa Neto, M.D., Ph.D.,
Marcus J. Schultz, M.D., Ph.D., Paolo Pelosi, M.D., F.E.R.S., Jochen Schmitt, M.D., Ph.D., Marcelo Gama
de Abreu, M.D., M.Sc., Ph.D., D.E.S.A.
Perioperative Medicine Anesthesiology June 2016, Vol. 124, 1230–1245

A systematic literature review was conducted for randomized controlled trials fulfilling following
criteria: (1) population: adult patients undergoing general anesthesia for surgery; (2) intervention:
patients receiving sevoflurane, desflurane, or isoflurane; (3) comparison: volatile anesthetics versus total
IV anesthesia or volatile anesthetics; (4) reporting on: (a) mortality (primary outcome) and (b)
postoperative pulmonary or other complications; (5) study design: randomized controlled trials.

Results
Sixty-eight randomized controlled trials with 7,104 patients were retained for analysis. In cardiac
surgery, volatile anesthetics were associated with reduced mortality (OR = 0.55; 95% CI, 0.35 to
0.85; P = 0.007), less pulmonary (OR = 0.71; 95% CI, 0.52 to 0.98; P = 0.038), and other complications
(OR = 0.74; 95% CI, 0.58 to 0.95; P = 0.020). In noncardiac surgery, volatile anesthetics were not
associated with reduced mortality (OR = 1.31; 95% CI, 0.83 to 2.05, P = 0.242) or lower incidences of
pulmonary (OR = 0.67; 95% CI, 0.42 to 1.05; P = 0.081) and other complications (OR = 0.70; 95% CI,
0.46 to 1.05; P = 0.092).
Conclusions
In cardiac, but not in noncardiac, surgery, when compared to total IV anesthesia, general
anesthesia with volatile anesthetics was associated with major benefits in outcome, including
reduced mortality, as well as lower incidence of pulmonary and other complications.

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Desflurane reinforces the efficacy of propofoltarget-controlled infusion in
patients undergoinglaparoscopic cholecystectomy
Po-Nien Chen, I-Cheng Lu b , Hui-Ming Chen , Kuang-I Cheng , Kuang-Yi Tseng ,
King-Teh Lee
Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung,Taiwan b Faculty of
Anesthesiology, College of Medicine, Kaohsiung Medical University, Kaohsiung,Taiwan c Faculty of
Surgery, College of Medicine, Kaohsiung Medical University, Kaohsiung,Taiwan
Kaohshiung Journal of Medical Sciences January2016 ,32-37

Low-concentration desflurane reinforces propofol-based intravenous anesthesia on maintenance of anesthesia for

patients undergoing laparoscopic cholecystectomy is to be determined. Fifty-two patients undergoing
laparoscopic cholecystectomy were enrolled in the prospective, randomized, clinical trial. Induction of anesthesia
was achieved in all patients with fentanyl 2 mg/kg, lidocaine 1 mg/kg, propofol 2 mg/kg, and rocuronium 0.8 mg/kg
to facilitate tracheal intubation and to initiate propofol target-controlled infusion (TCI) to effect site
concentration (Ce: 4 mg/mL with infusion rate 400 mL/h). The patients were then allocated into either propofol
TCI based (group P) or propofol TCI adding low-concentration desflurane (group PD) for maintenance of
anesthesia. The peri-anesthesia hemodynamic responses to stimuli were measured. The perioperative
psychomotor test included p-deletion test, minus calculation, orientation, and alert/sedation scales. Group PD
showed stable hemodynamic responses at CO2 inflation, initial 15 minutes of operation, and recovery from
general anesthesia as compared with group P. There is no significant difference between the groups in operation
time and anesthesia time, perioperative psychomotor functional tests, postoperative vomiting, and pain score.
Based on findings, the anesthetic technique combination propofol and desflurane for the maintenance of
general anesthesia for laparoscopic cholecystectomy provided more stable hemodynamic responses than
propofol alone. The combined regimen is recommended for patients undergoing laparoscopic cholecystectomy.

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Comparison of propofol and volatile agents for maintenance of anaesthesia
during elective craniotomy procedures: systematic review and meta-analysis
•Jason Chui• Ramamani Mariappan• Jigesh Mehta . Laksmi . Manninen.
Canadian Anesthesiologists’ Society 2017

Primary outcome: Secondary outcome:

Intra-operative brain Cerebral haemodynamic &
relaxation score neurological outcome

Results:
Conclusion:
14 studies (1,819 pts)
Propofol maintained
Brain relaxation score similar, anaesthesia =
ICP lower & CPP higher in volatile-maintained anaesthesia
propofol-maintained
anaesthesia

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 Brain
Relaxation
Score

1 = bulging 3=
2 = firm 4 = perfectly
brain satisfactorily
brain relaxed
relaxed

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For Healthcare Professionals Only. MY-PH49-210010 04/21
Desflurane-based Enhanced Recovery After Surgery (D-
ERAS) Pathway for Primary Hip and Knee Arthroplasty

Study Type : Interventional (Clinical Trial)

Estimated Enrollment 640 participants
:
The primary outcome is LOS in hospital. Secondary outcomes include Postoperative
Allocation: Randomized LOS, all-cause mortality by 30 days after operation, in-hospital complications,
mobilization, postoperative pain evaluation, total in-hospital cost, and
Intervention Model: Parallel Assignment readmission rate by 30 days after discharge from the hospital
Masking: Single (Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Enhanced Recovery After Surgery (ERAS) Pathway for Primary Hip and Knee Arthroplasty: a
Prospective, Controlled, Randomized Clinical Trial

Estimated Study Start March 1, 2020
Date :
Estimated Primary January 31, 2021
Completion Date :
Estimated Study January 31, 2022
Completion Date :
Procedure: The ERAS groupERAS pathway for orthopedic surgeons:
1.Shortened preoperative fasting from intake.
2.Preoperative tranexamic acid administration.
3.No indwelling catheters.
4.No tourniquet used for TKA.
5.No drainage tube.
6.Application of the low molecular heparin 6 hours after the operation.
ERAS pathway for anesthesiologist:
1.Intravenous 20 mg of dexamethasone before anesthetic induction.
2.Anesthesia will be induced with small dose of long-acting opioids such as sulfentanil, or without
long-acting opioids at all.
3.Laryngeal mask for airway.
4.Anesthesia will be maintained with short-acting anesthetic agents such as desflurane, sevoflurane,
or propofol, with continuous remifentanil , and BIS value will be kept between 40 to 60 during
procedure.
5.Incision infiltration with 40-50ml of 0.2% ropivacaine, and no patient controlled intravenous
analgesia devices will be applied.

For Healthcare Professionals Only. MY-PH49-210010 04/21

For Healthcare Professionals Only. MY-PH49-210010 04/21
Points to Ponder….

• Standardization of care

• Evidence based care

• Multimodal care pathway based on best

evidence
• Multidisciplinary (focus on the team)

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Thank You
….for your attention

You can make the

critical difference!

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