Effects of a novel method of anesthesia combining propofol and volatile anesthesia on the incidence of postoperative nausea and vomiting in patients undergoing laparoscopic gynecological surgery Presented in part at the 57th Annual Meeting of the Japanese Society of Anesthesiologists, Fukuoka, Japan, 3-5 June 2010.

Hiroaki Kawano Naohiro Ohshita Kimiko Katome Takako Kadota Michiko Kinoshita Yayoi Matsuoka Yasuo M. Tsutsumi Shinji Kawahito Katsuya Tanaka Shuzo Oshita About the authors

Abstracts

BACKGROUND:

We investigated the effects of a novel method of anesthesia combining propofol and volatile anesthesia on the incidence of postoperative nausea and vomiting in patients undergoing laparoscopic gynecological surgery.

METHODS:

Patients were randomly divided into three groups: those maintained with sevoflurane (Group S, n = 42), propofol (Group P, n = 42), or combined propofol and sevoflurane (Group PS, n = 42). We assessed complete response (no postoperative nausea and vomiting and no rescue antiemetic use), incidence of nausea and vomiting, nausea severity score, vomiting frequency, rescue antiemetic use, and postoperative pain at 2 and 24 h after surgery.

RESULTS:

The number of patients who exhibited a complete response was greater in Groups P and PS than in Group S at 0-2 h (74%, 76% and 43%, respectively, p = 0.001) and 0-24 h (71%, 76% and 38%, respectively, p < 0.0005). The incidence of nausea at 0-2 h (Group S = 57%, Group P = 26% and Group PS = 21%, p = 0.001) and 0-24 h (Group S = 62%, Group P = 29% and Group PS = 21%, p < 0.0005) was also significantly different among groups. However, there were no significant differences among groups in the incidence or frequency of vomiting or rescue antiemetic use at 0-24 h.

CONCLUSION:

Combined propofol and volatile anesthesia during laparoscopic gynecological surgery effectively decreases the incidence of postoperative nausea. We term this novel method of anesthesia "combined intravenous-volatile anesthesia (CIVA)".

Postoperative nausea and vomiting; Propofol; Sevoflurane; General anesthesia; Laparoscopy


JUSTIFICATIVA:

Investigamos os efeitos de um novo método de anestesia, que combina propofol e anestesia volátil, sobre a incidência de náusea e vômito no período pós-operatório de pacientes submetidas à laparoscopia ginecológica.

MÉTODOS:

As pacientes foram randomicamente divididas em três grupos: manutenção com sevoflurano (Grupo S, n = 42), com propofol (Grupo P, n = 42) ou com a combinação de propofol e sevoflurano (Grupo PS, n = 42). Avaliamos as respostas completas (sem náusea e vômito no pós-operatório e sem uso de antiemético de resgate), incidência de náusea e vômito, escore de gravidade da náusea, frequência de vômitos, uso de antiemético de resgate e dor no pós-operatório em duas e 24 horas após a cirurgia.

RESULTADOS:

O número de doentes que apresentou uma resposta completa foi maior nos grupos P e PS do que no Grupo S em 0-duas horas (74%, 76% e 43%m respectivamente, p = 0,001) e 0-24 horas (71%, 76% e 38%, respectivamente, p < 0,0005). A incidência de náusea em 0-duas horas (Grupo S = 57%, Grupo P = 26% e Grupo PS = 21%, p = 0,001) e 0-24 horas (Grupo S = 62%; Grupo P = 29% e grupo PS = 21%, p < 0,0005) também foi significativamente diferente entre os grupos. Porém, não houve diferença significativa entre os grupos em relação à incidência ou frequência de vômitos ou uso de antiemético de resgate em 0-24 horas.

CONCLUSÃO:

A combinação de propofol e anestesia volátil durante a laparoscopia ginecológica efetivamente diminui a incidência de náusea no pós-operatório.

Náusea e vômito pós-operatórios; Propofol; Sevoflurano; Anestesia geral; Laparoscopia


Introduction

Volatile anesthetics exert cardioprotective effects mediated by the activation of adenosine triphosphate-sensitive potassium (KATP) channels in cardiac myocytes.11. Tanaka K, Weihrauch D, Ludwig LM, et al. Mitochondrial adenosine triphosphate-regulated potassium channel opening acts as a trigger for isoflurane-induced preconditioning by generating reactive oxygen species. Anesthesiology. 2003;98: 935-43.and22. Tanaka K, Ludwig LM, Kersten JR, et al. Mechanisms of cardioprotection by volatile anesthetics. Anesthesiology. 2004;100:707-21. They also affect coronary vasodilation by activating KATP channels in vascular smooth muscle cells.3 3. Crystal GJ, Gurevicius J, Salem MR, et al. Role of adenosine triphosphate-sensitive potassium channels in coronary vasodi- lation by halothane, isoflurane, and enflurane. Anesthesiology. 1997;86:448-58.and44. Zhou X, Abboud W, Manabat NC, et al. Isoflurane-induced dila- tion of porcine coronary arterioles is mediated by ATP-sensitive potassium channels. Anesthesiology. 1998;89:182-9. Therefore, the use of volatile anesthetics for clinical anesthesia may be beneficial in prevention of coronary artery disease.

Total intravenous anesthesia (TIVA) with propofol also has many advantages. It decreases the incidence of postoperative nausea and vomiting (PONV),55. Habib AS, White WD, Eubanks S, et al. A randomized compari- son of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. Anesth Analg. 2004;99:77-81.and66. Mukherjee K, Seavell C, Rawlings E, et al. A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and condi- tions of surgery. Anaesthesia. 2003;58:176-80. decreases cerebral blood flow and intracranial pressure,77. Pinaud M, Lelausque JN, Chetanneau A, et al. Effects of propo- fol on cerebral hemodynamics and metabolism in patients with brain trauma. Anesthesiology. 1990;73:404-9. and attenuates postoperative pain88. Cheng SS, Yeh J, Flood P. Anesthesia matters: patients anes- thetized with propofol have less postoperative pain than those anesthetized with isoflurane. Anesth Analg. 2008;106:264-9, table of contents. and neuroendocrine stress response.99. Marana E, Colicci S, Meo F, et al. Neuroendocrine stress response in gynecological laparoscopy: TIVA with propofol versus sevoflu- rane anesthesia. J Clin Anesth. 2010;22:250-5.

Because of these benefits combined with the rapid onset and cessation of action, both volatile anesthetics and propofol are extensively used for clinical anesthesia.

We hypothesized that a novel method of anesthesia combining propofol and volatile anesthesia can provide the benefits of both while decreasing the disadvantages of each anesthetic. In this study, we investigated the effects of combined propofol and volatile anesthesia on the incidence of PONV in patients undergoing laparoscopic gynecological surgery.

Materials and methods

After obtaining approval for this study from the Ethics Committee on Human Studies of Tokushima University Hospital, written informed consent was obtained from all patients. All patients were scheduled for elective laparoscopic gynecological surgery (removal of ovarian tumors and cysts, adhesiolysis, myomectomy, salpingostomy, ovarian drilling and oophorectomy) under general endotracheal anesthesia, with an American Society of Anesthesiologists (ASA) physical status of I and II. The study's exclusion criteria were as follows: obesity (body mass index >33 kg/m2); neurological, renal, or liver disease; and the use of drugs with antiemetic properties, including corticosteroids. Risk factors associated with PONV were recorded.

Patients were randomly assigned to one of the following three groups by the sealed envelope method: those maintained with sevoflurane (Group S), those maintained with propofol (Group P), and those maintained with combined propofol and sevoflurane (Group PS).

No preanesthetic medication was administered. All patients were monitored by electrocardiography, noninvasive arterial blood pressure measurement, pulse oximetry, capnography, and the bispectral index (BIS) monitoring. No nasogastric tubes were inserted. General anesthesia was induced with intravenous remifentanil, thiamylal (Group S) or propofol (Groups P and PS) and rocuronium. Anesthesia was maintained with remifentanil and sevoflurane, propofol, or combined propofol and sevoflurane in 2:1 air and oxygen.

In Group S, anesthesia was maintained with sevoflurane (end-tidal concentration approximately 1 minimum alveolar concentration). In Group P, anesthesia was maintained with an infusion of propofol (4-8 mg/kg/h). In Group PS, anesthesia was maintained with combined propofol (2 mg/kg/h) and sevoflurane (end-tidal concentration approximately 0.5 minimum alveolar concentrations). Sevoflurane concentration (Group S) and propofol infusion rates (Group P) were titrated to achieve a target BIS value of 40-60. In Group PS, propofol infusion rate and sevoflurane concentration were fixed.

Intraoperative analgesia was performed by titrating remifentanil infusion at the discretion of the attending anesthesiologist. Neuromuscular blockade was maintained with intermittent rocuronium. Ringer's acetate solution was administered at 10 mL/kg/h for the first hour of anesthesia and at 5 mL/kg/h for all subsequent hours. Before the end of surgery, all patients received flurbiprofen axetil (1 mg/kg). At the end of surgery, neuromuscular blockade was reversed with atropine (0.5 mg) and neostigmine (1 mg).

The incidence and severity of PONV were assessed by blinded observers at 2 and 24 h after surgery. The severity of nausea was recorded using the following scale: no nausea, mild nausea, moderate nausea, and severe nausea. A complete response was defined as no PONV and no rescue antiemetic use. Intravenous metoclopramide (10 mg) was used as the rescue antiemetic. Postoperative pain was evaluated using a numerical rating scale (0 = no pain to 10 = maximal pain). When a patient requested analgesia, a diclofenac suppository (25 mg) or intramuscular pentazocine (15 mg) was administered. The 0-2 h and 2-24 h intervals were defined as early and late, respectively. The primary end point was the complete response rate within 24 h of surgery.

A previous study1010. Boehler M, Mitterschiffthaler G, Schlager A. Korean hand acu- pressure reduces postoperative nausea and vomiting after gyne- cological laparoscopic surgery. Anesth Analg. 2002;94:872-5, table of contents. reported a cumulative PONV incidence of 70% at 24 h in patients undergoing laparoscopic gynecological surgery. The sample size was determined by power analysis to provide a power of 0.8 to detect a 35% absolute decrease in the cumulative PONV incidence (a = 0.05). Statistical analysis was performed with SPSS(r) version 18 (SPSS Inc., Chicago, IL, USA). Continuous variables were compared by one-way analysis of variance, with Bonferroni post hoc tests for multiple comparisons. Categorical variables were analyzed using the χ22. Tanaka K, Ludwig LM, Kersten JR, et al. Mechanisms of cardioprotection by volatile anesthetics. Anesthesiology. 2004;100:707-21. or Fisher's exact tests, with correction for multiple comparisons where appropriate. Data are expressed as number of patients or mean ± standard deviation. A p-value of <0.05 was considered statistically significant.

Results

Of 130 patients, four were excluded from this analysis: two who converted to laparotomy and two violated the study protocol. Therefore, 42 patients were randomly allocated to Group S, 42 to Group P, and 42 to Group PS.

Demographic data were similar with respect to age, weight, height, ASA physical status, smoking history, history of motion sickness and/or PONV, and menstrual cycle phase (Table 1). Similarly, there were no significant differences in intraoperative variables, including the duration of anesthesia and surgery, total doses of remifentanil and rocuronium, surgery type, temperature, blood loss, and intravascular fluid volume (Table 2).

Table 1.
Patient demographics.

Table 2.
Surgery/anesthesia-related parameters.

A complete response at 24 h (primary end point) was achieved in 38% patients in Group S, 71% in Group P and 76% in Group PS (p < 0.0005) (Table 3). Groups P and PS differed significantly from Group S (p = 0.012 and < 0.002, respectively), but no significant difference was evident between Groups P and PS (Table 3). The incidence of nausea at 24 h was also significantly different (Group S = 62%, Group P = 29% and Group PS = 21%, p < 0.0005). The significant nausea rate was also lower in Group P and PS than in Group S (p = 0.003). However, there were no statistically significant differences among groups in the incidence or frequency of vomiting or rescue antiemetic use at 24 h (Table 3).

Table 3.
Incidence of postoperative nausea and vomiting.

In the early postoperative period, the proportion of patients who experienced a complete response was significantly higher in Groups P (74%) and PS (76%) than in Group S (43%) (p = 0.001). The incidence of nausea was also significantly lower in Groups P (26%) and PS (21%) than in Group S (57%) (p = 0.001). However, there were no statistically significant differences among groups in the incidence or frequency of vomiting at this time (Table 3).

In the late postoperative period, although the incidence of nausea was lower in Groups P (12%) and PS (10%) than in Group S (26%), the difference was not statistically significant (p = 0.078). The proportion of patients exhibiting a complete response, the incidence and frequency of vomiting, severity of nausea, and rescue antiemetic use did not differ among groups during at this time (Table 3).

There was no difference among groups in the numerical rating scale or analgesia use (Table 4). No patients reported intraoperative awareness.

Table 4.
Postoperative pain data.

Discussion

This study demonstrates that the use of combined propofol and sevoflurane anesthesia during laparoscopic gynecological surgery decreases PONV incidence. This is the first study, as per our knowledge, to assess the effects of combined propofol and volatile anesthesia on PONV incidence.

The use of volatile anesthetics such as isoflurane and sevoflurane has many benefits. The representative beneficial effect is cardioprotection. Volatile anesthetics have been shown to protect the myocardium against myocardial ischemia and reperfusion injury through a signal transduction pathway that includes protein kinase C and mitochondrial and sarcolemmal KATP channels.11. Tanaka K, Weihrauch D, Ludwig LM, et al. Mitochondrial adenosine triphosphate-regulated potassium channel opening acts as a trigger for isoflurane-induced preconditioning by generating reactive oxygen species. Anesthesiology. 2003;98: 935-43.and22. Tanaka K, Ludwig LM, Kersten JR, et al. Mechanisms of cardioprotection by volatile anesthetics. Anesthesiology. 2004;100:707-21. Reportedly,33. Crystal GJ, Gurevicius J, Salem MR, et al. Role of adenosine triphosphate-sensitive potassium channels in coronary vasodi- lation by halothane, isoflurane, and enflurane. Anesthesiology. 1997;86:448-58.and44. Zhou X, Abboud W, Manabat NC, et al. Isoflurane-induced dila- tion of porcine coronary arterioles is mediated by ATP-sensitive potassium channels. Anesthesiology. 1998;89:182-9. volatile anesthetics also cause coronary vasodilatation by activating vascular KATP channels. Randomized clinical trials in patients undergoing coronary artery surgery have demonstrated that volatile anesthetics decrease troponin release, the duration of intensive care unit stay, and the incidence of late cardiac events and enhance left ventricular function.1111. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guide- lines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiolo- gists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vas- cular Surgery. Circulation. 2007;116:e418-99. On the basis of these trials, the American College of Cardiology/American Heart Association 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery1111. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guide- lines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiolo- gists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vas- cular Surgery. Circulation. 2007;116:e418-99. recommend the use of volatile anesthetic agents during noncardiac surgery for maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Class IIa, level of evidence B). The additional benefits of volatile anesthesia include a lower incidence of intraoperative awareness during general anesthesia1212. Ghoneim MM. Awareness during anesthesia. Anesthesiology. 2000;92:597-602. and a bronchodilatory effect.1313. Pabelick CM, Prakash YS, Kannan MS, et al. Effects of halothane on sarcoplasmic reticulum calcium release channels in porcine airway smooth muscle cells. Anesthesiology. 2001;95:207-15.

TIVA with propofol is associated with a lower PONV incidence.55. Habib AS, White WD, Eubanks S, et al. A randomized compari- son of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. Anesth Analg. 2004;99:77-81.and66. Mukherjee K, Seavell C, Rawlings E, et al. A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and condi- tions of surgery. Anaesthesia. 2003;58:176-80. In addition, TIVA has many advantages over volatile anesthesia. Several studies77. Pinaud M, Lelausque JN, Chetanneau A, et al. Effects of propo- fol on cerebral hemodynamics and metabolism in patients with brain trauma. Anesthesiology. 1990;73:404-9. have shown that propofol causes a dose-related decrease in cerebral blood flow, the rate of cerebral metabolism of oxygen, and intracranial pressure. Animal studies1414. Ishibe Y, Gui X, Uno H, et al. Effect of sevoflurane on hypoxic pulmonary vasoconstriction in the perfused rabbit lung. Anes- thesiology. 1993;79:1348-53. have demonstrated that volatile anesthetics inhibit hypoxic pulmonary vasoconstriction (HPV) in a dose-dependent manner, although propofol does not seem to affect HPV.1515. Schwarzkopf K, Schreiber T, Preussler NP, et al. Lung perfusion, shunt fraction, and oxygenation during one-lung ventilation in pigs: the effects of desflurane, isoflurane, and propofol. J Car- diothorac Vasc Anesth. 2003;17:73-5. Although it remains controversial whether propofol can induce malignant hyperthermia (MH),1616. Migita T, Mukaida K, Hamada H, et al. Effects of propofol on cal- cium homeostasis in human skeletal muscle. Anaesth Intensive Care. 2009;37:415-25. Sumitani et al.1717. Sumitani M, Uchida K, Yasunaga H, et al. Prevalence of malig- nant hyperthermia and relationship with anesthetics in Japan: data from the diagnosis procedure combination database. Anes- thesiology. 2011;114:84-90. reported a relatively low prevalence of MH in propofol users. Previous studies88. Cheng SS, Yeh J, Flood P. Anesthesia matters: patients anes- thetized with propofol have less postoperative pain than those anesthetized with isoflurane. Anesth Analg. 2008;106:264-9, table of contents. have demonstrated that patients anesthetized with propofol experience less pain than those anesthetized with volatile anesthetics. Furthermore, TIVA was shown to be more effective in inhibiting the neuroendocrine stress response compared with volatile anesthesia.99. Marana E, Colicci S, Meo F, et al. Neuroendocrine stress response in gynecological laparoscopy: TIVA with propofol versus sevoflu- rane anesthesia. J Clin Anesth. 2010;22:250-5. Propofol may also prevent tissue damage resulting from oxidative stress1818. Nakahata K, Kinoshita H, Azma T, et al. Propofol restores brain microvascular function impaired by high glucose via the decrease in oxidative stress. Anesthesiology. 2008;108:269-75. through its antioxidant properties.1919. Murphy PG, Myers DS, Davies MJ, et al. The antioxidant potential of propofol (2,6-diisopropylphenol). Br J Anaesth. 1992;68:613-8.

Propofol and volatile anesthetics such as sevoflurane and desflurane are extensively used for clinical anesthesia because of the rapid onset and cessation of action. The use of each anesthetic has both advantages and disadvantages. We developed a novel method of anesthesia combining propofol and volatile anesthesia to receive the benefits and decrease the disadvantages of each anesthetic. However, this was just a hypothesis, and the actual effects of combination remain unknown. Therefore, we evaluated the effects of combined propofol and volatile anesthesia on PONV incidence in patients undergoing laparoscopic gynecological surgery.

The results of this study showed that the use of combined propofol and volatile anesthesia during laparoscopic gynecological surgery caused a 66% reduction in PONV (from 62% to 21%), an effect that was more pronounced in the early postoperative period. Surprisingly, this effect is comparable with that of TIVA with propofol (a 66% decrease in Group PS versus a 53% decrease in Group P). The PONV incidence in Group S (62%) was similar to the previously reported PONV incidence undergoing laparoscopic gynecological surgery. 1010. Boehler M, Mitterschiffthaler G, Schlager A. Korean hand acu- pressure reduces postoperative nausea and vomiting after gyne- cological laparoscopic surgery. Anesth Analg. 2002;94:872-5, table of contents.and2020. Eriksson H, Korttila K. Recovery profile after desflurane with or without ondansetron compared with propofol in patients undergoing outpatient gynecological laparoscopy. Anesth Analg. 1996;82:533-8.

Patients in Group PS received significantly smaller doses of sevoflurane during anesthesia, which may explain the decreased PONV incidence. Apfel et al.2121. Apfel CC, Kranke P, Katz MH, et al. Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design. Br J Anaesth. 2002;88:659-68. reported that the degree of exposure to volatile anesthetics is the primary cause of PONV in the early postoperative period. Another reason for the decreased PONV incidence could be the antiemetic effects of propofol. The antiemetic properties of propofol were first demonstrated by Borgeat et al.2222. Borgeat A, Wilder-Smith OH, Saiah M, et al. Subhypnotic doses of propofol possess direct antiemetic properties. Anesth Analg. 1992;74:539-41. and subsequently by several other authors.2323. Gan TJ, Ginsberg B, Grant AP, et al. Double-blind, random- ized comparison of ondansetron and intraoperative propofol to prevent postoperative nausea and vomiting. Anesthesiology. 1996;85:1036-42. However, its precise mechanism of action remains unclear. Propofol may act as a dopamine receptor antagonist.2424. DiFlorio T. Is propofol a dopamine antagonist? Anesth Analg. 1993;77:200-1. It has also been shown to possess a weak antagonistic effect against serotonin. However, the precise mechanism by which propofol exerts its antiemetic effects remain undetermined. Reportedly,2525. Gan TJ, Glass PS, Howell ST, et al. Determination of plasma concentrations of propofol associated with 50% reduction in postoperative nausea. Anesthesiology. 1997;87:779-84. the effect is associated with a defined plasma concentration range; the plasma propofol concentration associated with a 50% decrease in nausea scores was found to be 343 ng/mL. According to the pharmacokinetic simulation (TIVA trainer 8, Frank Engbers, Leiden, The Netherlands), 155 min after an induction dose of 1.5 mg/kg and maintenance with 2 mg/kg/h, the plasma concentration of propofol is 1 µg/mL. Simulation data also demonstrate that the plasma propofol concentration drops below 350 ng/mL within approximately 170 min of the end of infusion. These simulation data suggest that the plasma concentration of propofol used in our method will above the range effective for antiemesis until approximately 170 min after the end of surgery. This probably explains why patients in Group PS exhibited a lower incidence of PONV, particularly in the early postoperative period.

Limitations of the study

Our study has some limitations. First, there is increasing consensus that better PONV prophylaxis can be achieved through the use of a combination of agents acting on different receptors, considering that multiple receptors are involved in the etiology of PONV. In high-risk patients, a multimodal approach to prevent PONV has been recommended. However, we did not administer any prophylactic antiemetic or combined agents to prevent PONV. This is because we wanted to investigate the baseline risk, which could have been masked by prophylactic antiemetic. Decreasing the baseline risk has been recommended2626. Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg. 2003;97:62-71, table of contents. because it can significantly decrease PONV incidence.27 27. Tramer MR. A rational approach to the control of post- operative nausea and vomiting: evidence from systematic reviews. Part I. Efficacy and harm of antiemetic interventions, and methodological issues. Acta Anaesthesiol Scand. 2001;45: 4-13.and2828. Tramer MR. A rational approach to the control of post- operative nausea and vomiting: evidence from systematic reviews. Part II. Recommendations for prevention and treat- ment, and research agenda. Acta Anaesthesiol Scand. 2001;45: 14-9. In addition, prophylactic antiemetic are associated with an increase in both costs and adverse effects.2929. Scholz J, Steinfath M, Tonner PH. Postoperative nausea and vomiting. Curr Opin Anaesthesiol. 1999;12:657-61.and3030. Allan BT, Smith I. Cost considerations in the use of anaesthetic drugs. Curr Opin Anaesthesiol. 2002;15:227-32. Therefore, we considered it important to study the pure incidence of PONV for each method of anesthesia. Second, only one combination of propofol infusion rate and sevoflurane concentration was studied, and the effects of other combinations were not assessed in this study. Therefore, the optimal combination of propofol infusion rate and sevoflurane concentration remains to be determined.

Conclusions

In conclusion, combined propofol and volatile anesthesia during laparoscopic gynecological surgery effectively decreases PONV incidence in the absence of prophylactic antiemetic. Although further experimental research is required to clarify its efficacy in a clinical context, we believe that combined propofol and volatile anesthesia offers potential clinical benefits. We term this novel method of anesthesia "combined intravenous-volatile anesthesia (CIVA)".

References

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    Tanaka K, Ludwig LM, Kersten JR, et al. Mechanisms of cardioprotection by volatile anesthetics. Anesthesiology. 2004;100:707-21.
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    Crystal GJ, Gurevicius J, Salem MR, et al. Role of adenosine triphosphate-sensitive potassium channels in coronary vasodi- lation by halothane, isoflurane, and enflurane. Anesthesiology. 1997;86:448-58.
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    Zhou X, Abboud W, Manabat NC, et al. Isoflurane-induced dila- tion of porcine coronary arterioles is mediated by ATP-sensitive potassium channels. Anesthesiology. 1998;89:182-9.
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    Habib AS, White WD, Eubanks S, et al. A randomized compari- son of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. Anesth Analg. 2004;99:77-81.
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    Mukherjee K, Seavell C, Rawlings E, et al. A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and condi- tions of surgery. Anaesthesia. 2003;58:176-80.
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    Pinaud M, Lelausque JN, Chetanneau A, et al. Effects of propo- fol on cerebral hemodynamics and metabolism in patients with brain trauma. Anesthesiology. 1990;73:404-9.
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    Cheng SS, Yeh J, Flood P. Anesthesia matters: patients anes- thetized with propofol have less postoperative pain than those anesthetized with isoflurane. Anesth Analg. 2008;106:264-9, table of contents.
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    Marana E, Colicci S, Meo F, et al. Neuroendocrine stress response in gynecological laparoscopy: TIVA with propofol versus sevoflu- rane anesthesia. J Clin Anesth. 2010;22:250-5.
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    Boehler M, Mitterschiffthaler G, Schlager A. Korean hand acu- pressure reduces postoperative nausea and vomiting after gyne- cological laparoscopic surgery. Anesth Analg. 2002;94:872-5, table of contents.
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    Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guide- lines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiolo- gists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vas- cular Surgery. Circulation. 2007;116:e418-99.
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    Ghoneim MM. Awareness during anesthesia. Anesthesiology. 2000;92:597-602.
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    Pabelick CM, Prakash YS, Kannan MS, et al. Effects of halothane on sarcoplasmic reticulum calcium release channels in porcine airway smooth muscle cells. Anesthesiology. 2001;95:207-15.
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    Ishibe Y, Gui X, Uno H, et al. Effect of sevoflurane on hypoxic pulmonary vasoconstriction in the perfused rabbit lung. Anes- thesiology. 1993;79:1348-53.
  • 15
    Schwarzkopf K, Schreiber T, Preussler NP, et al. Lung perfusion, shunt fraction, and oxygenation during one-lung ventilation in pigs: the effects of desflurane, isoflurane, and propofol. J Car- diothorac Vasc Anesth. 2003;17:73-5.
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    Migita T, Mukaida K, Hamada H, et al. Effects of propofol on cal- cium homeostasis in human skeletal muscle. Anaesth Intensive Care. 2009;37:415-25.
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    Sumitani M, Uchida K, Yasunaga H, et al. Prevalence of malig- nant hyperthermia and relationship with anesthetics in Japan: data from the diagnosis procedure combination database. Anes- thesiology. 2011;114:84-90.
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    Nakahata K, Kinoshita H, Azma T, et al. Propofol restores brain microvascular function impaired by high glucose via the decrease in oxidative stress. Anesthesiology. 2008;108:269-75.
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    Murphy PG, Myers DS, Davies MJ, et al. The antioxidant potential of propofol (2,6-diisopropylphenol). Br J Anaesth. 1992;68:613-8.
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    Eriksson H, Korttila K. Recovery profile after desflurane with or without ondansetron compared with propofol in patients undergoing outpatient gynecological laparoscopy. Anesth Analg. 1996;82:533-8.
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    Apfel CC, Kranke P, Katz MH, et al. Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design. Br J Anaesth. 2002;88:659-68.
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  • Presented in part at the 57th Annual Meeting of the Japanese Society of Anesthesiologists, Fukuoka, Japan, 3-5 June 2010.

Publication Dates

  • Publication in this collection
    Jan-Feb 2016

History

  • Received
    20 May 2014
  • Accepted
    03 July 2014
Sociedade Brasileira de Anestesiologia R. Professor Alfredo Gomes, 36, 22251-080 Botafogo RJ Brasil, Tel: +55 21 2537-8100, Fax: +55 21 2537-8188 - Campinas - SP - Brazil
E-mail: bjan@sbahq.org