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Background: Prospective interventional trials and retrospective observational analyses provide conflicting evidence regarding the relationship between propofol versus inhaled volatile general anesthesia and long-term survival after cancer surgery. Specifically, bladder cancer surgery lacks prospective clinical trial evidence., Methods: Data on bladder cancer surgery performed under general anesthesia between 2014 and 2021 from the National Quality Registry for Urinary Tract and Bladder Cancer and the Swedish Perioperative Registry were record-linked. Overall survival was compared between patients receiving propofol or inhaled volatile for anesthesia maintenance. The minimum clinically important difference was defined as a 5-percentage point difference in 5-yr survival., Results: Of 7,571 subjects, 4,519 (59.7%) received an inhaled volatile anesthetic, and 3,052 (40.3%) received propofol for general anesthesia maintenance. The two groups were quite similar in most respects but differed in American Society of Anesthesiologists Physical Status and tumor stage. Propensity score matching was used to address treatment bias. Survival did not differ during follow-up (median, 45 months [interquartile range, 33 to 62 months]) in the full unmatched cohort nor after 1:1 propensity score matching (3,052 matched pairs). The Kaplan-Meier adjusted 5-yr survival rates in the matched cohort were 898 of 3,052, 67.5% (65.6 to 69.3%) for propofol and 852 of 3,052, 68.5% (66.7 to 70.4%) for inhaled volatile general anesthesia, respectively (hazard ratio, 1.05 [95% CI, 0.96 to 1.15]; P = 0.332). A sensitivity analysis restricted to 1,766 propensity score-matched pairs of patients who received only one general anesthetic during the study period did not demonstrate a difference in survival; Kaplan-Meier adjusted 5-yr survival rates were 521 of 1,766, 67.1% (64.7 to 69.7%) and 482 of 1,766, 68.9% (66.5 to 71.4%) for propofol and inhaled volatile general anesthesia, respectively (hazard ratio, 1.09 [95% CI, 0.97 to 1.23]; P = 0.139)., Conclusions: Among patients undergoing bladder cancer surgery under general anesthesia, there was no statistically significant difference in long-term overall survival associated with the choice of propofol or an inhaled volatile maintenance., (Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.)

Background: Several retrospective studies using administrative or single-center data have failed to show any difference between general anesthesia using propofol versus inhaled volatiles on long-term survival after breast cancer surgery. Although randomized controlled trials are ongoing, validated data from national clinical registries may advance the reliability of existing knowledge., Methods: Data on breast cancer surgery performed under general anesthesia between 2013 and 2019 from the Swedish PeriOperative Registry and the National Quality Registry for Breast Cancer were record-linked. Overall survival was compared between patients receiving propofol and patients receiving inhaled volatile for anesthesia maintenance., Results: Of 18,674 subjects, 13,873 patients (74.3%) received propofol and 4,801 (25.7%) received an inhaled volatile for general anesthesia maintenance. The two cohorts differed in most respects. Patients receiving inhaled volatile were older (67 yr vs. 65 yr), sicker (888 [19.0%] American Society of Anesthesiologists status 3 to 5 vs. 1,742 [12.8%]), and the breast cancer to be more advanced. Median follow-up was 33 months (interquartile range, 19 to 48). In the full, unmatched cohort, there was a statistically significantly higher overall survival among patients receiving propofol (13,489 of 13,873 [97.2%]) versus inhaled volatile (4,039 of 4,801 [84.1%]; hazard ratio, 0.80; 95% CI, 0.70 to 0.90; P < 0.001). After 1:1 propensity score matching (4,658 matched pairs), there was no statistically significant difference in overall survival (propofol 4,284 of 4,658 [92.0%]) versus inhaled volatile (4,288 of 4,658 [92.1%]; hazard ratio, 0.98; 95% CI, 0.85 to 1.13; P = 0.756)., Conclusions: Among patients undergoing breast cancer surgery under general anesthesia, no association was observed between the choice of propofol or an inhaled volatile maintenance and overall survival., (Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved.)

Background: Retrospective studies indicate that the choice of anesthetic can affect long-term cancer survival. Propofol seems to have an advantage over sevoflurane. However, this is questioned for breast cancer. We gathered a large cohort of breast cancer surgery patients from seven Swedish hospitals and hypothesized that general anesthesia with propofol would be superior to sevoflurane anesthesia regarding long-term breast cancer survival., Methods: We identified all patients who were anaesthetized for breast cancer surgery between 2006 and 2012. The patients were matched to the Swedish Breast Cancer Quality Register, to retrieve tumor characteristics, prognostic factors, and adjuvant treatment as well as date of death. Overall survival between patients undergoing sevoflurane and propofol anesthesia was analyzed with different statistical approaches: (a) multiple Cox regression models adjusted for demographic, oncological, and multiple control variables, (b) propensity score matching on the same variables, but also including the participating centers as a cofactor in a separate analysis., Results: The database analysis identified 6305 patients. The 5-year survival rates were 91.0% and 81.8% for the propofol and sevoflurane group, respectively, in the final model (P = .126). Depending on the statistical adjustment method used, different results were obtained, from a non-significant to a "proposed" and even a "determined" difference in survival that favored propofol, with a maximum of 9.2 percentage points higher survival rate at 5 years (hazard ratio 1.46, 95% CI 1.10-1.95)., Conclusions: It seems that propofol may have a survival advantage compared with sevoflurane among breast cancer patients, but the inherent weaknesses of retrospective analyses were made apparent., (© 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Different pharmacokinetic models for target controlled infusion (TCI) of propofol are available in the recently launched open TCI systems. There is also a compelling choice to work with either plasma- or effect-site targets. Knowledge about the clinical consequences of different alternatives is of importance. We aimed to illustrate the potential differences in the actual drug delivery/output between three present commercially available and clinically used pharmacokinetic models: the original Marsh model, which is also implemented in the Diprifusor, the "modified Marsh-" and the Schnider models. Simulations were made in the TivaTrainer program (eurosiva.com). Firstly, our standard plasma target regimen was simulated, and secondly an effect-site target of 3.5 microg/mL was chosen. Thirdly, real infusors were used for measuring the time to reach defined predicted effect-site concentrations when aiming at a plasma target of 6 microg/mL. Identical patient characteristics were used in all simulations: male, 170 cm, 70 kg, 40 years of age. Resulting predicted effect-site peak concentrations, and used bolus doses were recorded, as were the resulting plasma over-shoot, and time frames. The plasma target regimen gave predicted effect-site peaks in the different models ranging from 3.6 to 7.2 microg/mL, reached after 2(3/4) to 4 minutes. To reach the same effect-site target, the three models used bolus doses ranging from 68 to 150 mg given during 22 to 46 seconds. The predicted plasma concentration over-shoots varied from 5.0 to 13.4 microg/mL. There were obvious differences between the models in the time taken to reach defined effect-site concentrations. We observed clinically significant different results between the models. The choice of model will make a difference for the patient. To eliminate confusion - not necessarily to improve precision - we call for an optimised population based pharmacokinetic model for propofol - a consensus model!

A relationship has previously been described between individual mean isoflurane concentrations and the release of a marker of neuronal injury, adenylate kinase (AK), into the cerebrospinal fluid (CSF) after anaesthesia and orthognathic surgery. Likewise, reduced mental performance has been detected. Twenty-nine patients scheduled for orthognathic surgery were assigned to isoflurane- or propofol based anaesthesia, which was adjusted to a defined level with the aid of processed EEG and quantitative surface EMG. In the case of a mean arterial pressure (MAP) < 50 mmHg a phenylephrine infusion was started to keep the MAP above the minimal level, otherwise no regard was paid to the blood pressure, which never exceeded normal values. A lumbar puncture for CSF sampling was performed approximately 20 h postoperatively. The CSF sample was analysed for AK activity. Neuropsychological tests were performed the day prior to surgery and again in the period 4-8 weeks postoperatively. Five patients were re-examined by psychometry 12-30 months later. A release of AK into CSF was confirmed, equal in both groups. Correlation with the anaesthetic dose given was poor. Five patients from each group failed significantly in the postoperative neuropsychological tests. They differed in several demographic respects from the others. When five of the failed patients were re-examined 12-30 months later, three patients still performed poorly in the tests. Biochemical and neuropsychological disturbances were recorded in several patients objected to orthognathic surgery. The underlying mechanisms are unclear, including the role of the anaesthetic drugs or surgery itself.

Background: Due to a few reports of cerebral dysfunction in connection with isoflurane-induced hypotension and concomitant hypocapnia, positron emission tomography (PET) was used to measure cerebral oxygenation and blood flow during similar conditions with isoflurane or propofol., Methods: The short-lived radionuclide 15O was used for measurement of cerebral metabolic rate of oxygen (CMRO2), cerebral blood flow (CBF) and oxygen extraction ratio (OER) regionally in rhesus monkeys during normotensive/normocapnic and hypotensive/hypocapnic conditions, mean arterial pressure 100-110 and 50-65 mmHg and PaCO2 4.4-5.4 and 3.4-4.4 kPa, respectively. Isoflurane or propofol anaesthesia was given (n = 4 in both groups), supported with 70% nitrous oxide and preceded by ketamine anaesthesia (baseline)., Results: PET revealed wide variations in CBF between regions during isoflurane anaesthesia, particularly in comparison with propofol anaesthesia, while rCMRO2 decreased globally in a dose-dependent manner during both isoflurane and propofol anaesthesia. The metabolism-flow coupling was intact during propofol but not during isoflurane anaesthesia. Hypotension reduced rCBF, and rOER increased globally with both study drugs when changing from normo- to hypotension. However, this rOER increase was not significant when using PaCO2 as a covariate, and rOER was never above an arbitrary limit for hypoxia of 70%. Thus, hypocapnia, rather than hypotension, was responsible for the somewhat higher rOER measured., Conclusion: PET indicated adequate cerebral oxygenation during isoflurane and propofol anaesthesia, despite disparate blood-flow patterns. Hypotension and concomitant moderate hyperventilation reduced rCBF, but did not result in hypoxia.

It is well established that the immediate recovery after propofol or alfentanil anesthesia is short. Although the drugs themselves are more expensive than older drugs, a potential for saving costs arises. Concerning the benefits in terms of late recovery, less information is available. With vaginal termination of pregnancy (VTP), anesthesia is supposed to be the major cause of sick-leave. Does propofol and alfentanil anesthesia for VTP reduce sick-leave compared with thiopental and nitrous oxide anesthesia, and do the increased costs of the drugs outweigh the reduced costs of sick-leave? Data were obtained from 39 of 40 patients in ASA class I accepted for VTP and allocated to either propofol and alfentanil anesthesia (PA) or thiopental and nitrous oxide anesthesia (TN). A questionnaire was filled in by the patients at home after regaining full fitness. The number of patients with a sick-leave of 2 days or less in the groups was compared statistically with the number of patients with 3 days or more off work. The economic impact from the reported sick-leave was calculated for each study group, using data from national statistics. The figures were compared with the calculated costs of the drugs. The median number of days of sick-leave was 1 in the PA-group and 2 in the TN-group (range 0-3 and 0-5, respectively). Nineteen of the 20 patients in the PA-group and 13 of the 19 patients in the TN-group needed a short sick-leave period of 2 days or less (one-sided test of proportions, P < 0.05). At the time of the study each patient was paid 210 SEK/day from the social insurance system and the mean cost of the drugs was 72 and 15 SEK/patient in the PA- and TN-groups, respectively. Using the mean difference in sick-leave between the groups of 0.8 days/patient (rather than the difference in median values of 1), a net gain of 111 SEK/patient was the result of changing from thiopental-nitrous oxide anesthesia to propofol-alfentanil anesthesia. Although the cost of drugs was higher, costs for the social insurance system and for the individuals themselves were reduced by almost 50%, when using the propofol and alfentanil combination, resulting in an overall benefit corresponding to almost twice the increase in the cost of anesthesia.