article information

Anesthesiology and Pain Medicine: Vol.9, issue 6; e96559
published online: December 3, 2019
article type: Research Article
received: July 22, 2019
revised: September 25, 2019
accepted: September 30, 2019
DOI: https://doi.org/10.5812/aapm.96559
Crossmark

Effect of Intravenous Propofol and Inhaled Sevoflurane Anesthesia on Postoperative Spirometric Indices: A Randomized Controlled Trial

authors:

avatar Mohammad Hajijafari ORCID 1 , * , avatar Leila Mehrzad 1 , avatar Fatemah Sadat Asgarian 2 , avatar Hossein Akbari 3 , avatar Mohammad Hossein Ziloochi ORCID 3

Department of Anesthesiology, Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
School of Public Health, Kashan University of Medical Sciences, Kashan, Iran

how to cite: Hajijafari M, Mehrzad L, Asgarian F S, Akbari H, Ziloochi M H. Effect of Intravenous Propofol and Inhaled Sevoflurane Anesthesia on Postoperative Spirometric Indices: A Randomized Controlled Trial. Anesth Pain Med. 2019;9(6):e96559. https://doi.org/10.5812/aapm.96559.

Abstract

Background:

Anesthetic drugs may directly or indirectly affect respiratory function. We investigated the effects of intravenous propofol and inhaled sevoflurane anesthesia on postoperative spirometric indices in patients undergoing inguinal herniorrhaphy surgery.

Methods:

We randomly assigned 111 patients, aged 18 - 65 years, undergoing inguinal herniorrhaphy surgery, to receive either intravenous propofol or inhaled sevoflurane. Forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and FEV1/FVC were measured before and after anesthesia. Comparisons between the two groups were made using the t-test and ANOVA.

Results:

There were no significant differences between the two groups in terms of age, sex, height, body weight, BMI, pain score, ASA class, operation duration, and received analgesics. The FEV1 and FVC values significantly decreased after the operation in the sevoflurane group.

Conclusions:

Both intravenous propofol and inhaled sevoflurane can decrease postoperative spirometry parameters. However, it seems that patients receiving propofol have less decreased spirometric indices.

1. Background

The induction of general anesthesia leads to changes in the respiratory system including the reduction of tidal volume (TV), forced expiratory volume in the first second (FEV1), and functional residual capacity (FRC) (1-3). Moreover, decreases in respiratory parameters have been shown after awakening from general anesthesia, especially in patients undergone intra-abdominal surgery (4). Researchers investigating postoperative pulmonary function have focused on the effects of surgery type (5-9), anesthesia type (10), positioning during surgery (11, 12), and some anesthetic techniques, interventions, and drugs (13-16).

Propofol that is commonly used in total intravenous anesthesia (TIVA) has anti-oxidant and inflammatory inhibition properties (17-19). It is known that TIVA can decrease postoperative nausea and vomiting (PONV) (20) with little effects on pulmonary functions (21).

Sevoflurane is an inhaled anesthetic with no irritation of the upper respiratory tract and low inhibition of respiration (22). Erturk suggests that sevoflurane may offer protection against reperfusion injury after one-lung ventilation in thoracic surgery (23). However, some studies have shown that inhalational anesthesia may cause perioperative pulmonary edema, thus affecting oxygen diffusion function (24) and it may inhibit or decrease the synthesis of pulmonary surfactants (25).

Some researchers have preferred TIVA to inhalational anesthesia for the prevention of PONV or chronic pain relief after anesthesia (20) while others found no significant differences between propofol-based TIVA and inhalational sevoflurane anesthesia in terms of postoperative pain, PONV, narcotic administration, and recovery time (17). Mensil et al. in a study on ICU patients concluded that long-term sedation using inhaled sevoflurane was safer and more effective than intravenous propofol, as it significantly reduced wake-up and extubation times and increased awakening quality (26).

2. Objectives

In the current study, we evaluated the effects of intravenous propofol and inhaled sevoflurane on postoperative spirometry indices in patients undergoing inguinal herniorrhaphy surgery. The patients in the two groups were matched for position during surgery, premedication, intubation, mechanical ventilation, and received analgesics.

3. Methods

After obtaining the ethics committee approval and patient informed consent, a double-blind randomized controlled trial was carried out on 111 patients aged between 18 and 65 with ASA class I or II, undergoing inguinal herniorrhaphy surgery at Naqavi University Hospital in Kashan, Iran, in 2018. Patients with severe cardiovascular diseases, CHF, COPD, chest deformity, drug abuse, BMI > 35, and history of anticonvulsant agent consumption were excluded from the study. Considering a 95% confidence interval, 80% power, and based on a similar study (27), the minimum sample size in each group was calculated as 55 patients. Using a permuted block randomization, the enrolled patients were divided into two groups of propofol and sevoflurane.

A standard spirometry test was done for all patients by a trained technician prior to the operation. The test was done at least three times for each patient and the best measurement was recorded. Routine monitoring consisted of pulse oximetry, NIBP, ECG, and capnography. All patients were placed in the supine position during the surgery. Also, the surgeon and the method of surgery were the same for all patients.

Anesthesia was induced with intravenous 2 μg/kg fentanyl, 2 mg midazolam, 2.5 mg/kg propofol, and 0.5 mg/kg atracurium. An endotracheal tube with suitable size and high-volume, low-pressure cuff was inserted for each patient. Anesthesia was maintained either with propofol 100 μg/kg/min (in one group) or with sevoflurane 2% - 2.5% (in the other group). Both groups received 30/70 % of the O2/N2O mixture during the operation. Mechanical ventilation was adjusted to achieve 35 - 45 mmHg of end-tidal carbon dioxide (ETCO2) concentration. All patients received 30 mg intravenous ketorolac 15 minutes before the end of anesthesia for postoperative pain control. After the completion of the surgery, all anesthetic agents discontinued. When spontaneous respiration was observed, the residual block was reversed by neostigmine 0.04 mg/kg and atropine 0.02 mg/kg. Extubation was performed when the patient could open the eyes or lift the head for five seconds. After extubation, the patients were routinely transferred to the recovery room. The duration of surgery and any episode of laryngospasm, bronchospasm, or drop in SpO2 were recorded. When the patient was completely alert, postoperative spirometry was done with the same technique and by the same technician who was blind to the type of intervention.

The data were analyzed by SPSS V. 16 software. The frequency, mean, and standard deviation were used to describe the data. To compare the two groups in terms of independent variables, the chi square test and Independent t-test were used for qualitative and quantitative data, respectively. The Independent t-test was also used to compare pain scores and operation duration between the two groups. The ANOVA test was used to determine differences between the groups. All P values were two-sided and P < 0.05 was considered statistically significant.

4. Results

Of 111 patients participating in the study, 56 patients were assigned to the propofol group and 55 patients were assigned to the sevoflurane group. No statistically significant differences were found between the two groups with respect to patient characteristics including sex, age, weight, height, BMI, ASA class, anesthesia time, pain score, and received analgesics (Table 1).

Table 1.

Demographic and Perioperative Variablesa

VariablesGroupsP Value
Propofol (N = 56)Sevoflurane (N = 55)
Sex0.485
Male47 (85.5)49 (87.5)
Female8 (14.5)7 (12.5)
Age43.75 ± 8.5741.84 ± 11.310.32
Weight72.64 ± 9.6173.91 ± 10.440.58
Height168.32 ± 7.06170.96 ± 8.650.082
BMI25.8 ± 4.3925.41 ± 3.980.62
ASA classification
Class I36 (65.5)40 (71.4)
Class II19 (34.5)16 (28.6)
Operation duration (min)32.73 ± 5.3434.11 ± 6.950.244
Pain score2.71 ± 0.812.70 ± 0.870.973
Rescue analgesics (mg)1.31 ± 1.671.11 ± 1.440.498

aValues are expressed as No. (%) or mean ± SD.

Postoperative FEV1 and FVC significantly decreased (P = 0.03 and P = 0.02, respectively) in the sevoflurane group while the change in postoperative FEV1/FVC was not significant (P = 0.52). In the propofol group, decreases in postoperative FEV1 and FVC were not statistically significant (P = 0.179); however, FEV1/FVC significantly decreased (P = 0.004) (Table 2).

Table 2.

Values of Pre- and Postoperative Spirometric Indicesa

FEV1FVCFEV1/FVC
Propofol (n = 56)
Before3.49 ± 0.614.25 ± 0.8579.96 ± 1.71
After3.44 ± 0.64.20 ± 0.8280.17 ± 2.82
P valueb0.030.0240.52
Sevoflurane (n = 55)
Before3.79 ± 0.534.63 ± 0.2279.96 ± 2.53
After3.74 ± 0.674.52 ± 0.6879.11 ± 2.76
P valueb0.520.1790.004
Postoperative changes
Sevoflurane0.05 ± 0.180.05 ± 0.16-0.21 ± 2.40
Propofol0.05 ± 0.590.11 ± 0.640.85 ± 2.14
P valuec0.4640.9670.464
P valued adjusted0.9760.5360.976

aValues are expressed as mean ± SD.

bPaired t-test.

cIndependent t-test.

dEffect of group in the analysis of covariance.

5. Discussion

This study showed reductions in postoperative FVC and FEV1 with both TIVA and inhalational sevoflurane anesthesia. However, these reductions were significant only in patients who had received inhaled sevoflurane. Previous studies have also reported reductions in FVC and FEV1 with TIVA and inhalational anesthesia, but the degree of FVC postoperative reduction was larger following TIVA than following sevoflurane anesthesia (4). Some other studies did not find significant decreases in FEV1 (16, 28). The probable reason for this difference may be the position of patients. Our patients were in the supine position during the surgery. Some researchers showed that changes in lung function were greater in the prone position (4, 11).

Decreased respiratory capacity after TIVA or inhalational anesthesia could be the result of changes in the contractility of respiratory muscles. Zhang et al. argued that propofol had inhibitory effects on diaphragmatic contractility in patients during general anesthesia. They found a decline in twitch diaphragmatic pressure in humans following a single bolus of propofol 2 mg/kg (29). It seems that anesthetic-induced decreases in respiratory muscles strength, especially the loss of diaphragmatic tone, can cause the occurrence of atelectasis with subsequent changes in FVC (4).

The postoperative pulmonary function has shown to be affected by surgery type and location. The literature emphasizes that decreased lung function is more obvious following abdominal surgery than following the peripheral operation (30). In this study, we tried to minimize the effect of surgery type and confounders by selecting lower abdominal surgery, in the supine position, using LMA.

The administration of narcotic drugs, before, during, or after the operation may affect pulmonary function (28, 31). Therefore, we restricted the narcotic agents at the operation time and used non-narcotic agents as alternatives for pain control.

Propofol-based TIVA has been associated with improved recovery profile and lower costs compared to sevoflurane for office-based anesthesia. This resulted in shorter recovery room stay, earlier discharge, and more patient satisfaction (20).

Rothen et al. argued that the reduction in FVC or FEV1 was strongly related to the development of atelectasis after the induction of general anesthesia (32). Kim et al. conducted a randomized study to compare the effects of propofol and desflurane on postoperative spirometry in the elderly after knee surgery. They concluded that the reduction in FVC was greater after TIVA with propofol-remifentanil than after sevoflurane-fentanyl-nitrous oxide anesthesia. However, TIVA had advantages such as less PONV, cough, and bronchoconstriction than inhalational anesthesia (33). We found reductions in postoperative FEV1/FVC in patients who had received propofol-based TIVA for their herniorrhaphy surgery.

Although statistically significant, the observed changes in postoperative pulmonary function test results were in the normal range, without clinical importance. Decreased lung function and compliance of the respiratory system could be attributed to atelectasis (11).

5.1. Conclusions

Although the present study confirmed previous findings of reductions in post-anesthesia spirometric indices, it showed that patients receiving propofol had less decreased pulmonary function. However, further studies are needed to evaluate the pulmonary effects of different anesthetics. Although the lung function is affected by decreased spirometric indices, the decision making on the selection of anesthesia depends on the particular clinical situation, other possible disorders, and surgical requirements and demands. This study showed that reductions in FVC and FEV following anesthesia were not very different using the two anesthetics. It seems that we should consider other factors such as the type of surgery, patient position, postoperative medications, and tracheal intubation with mechanical ventilation.

References

  • 1.

    Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118(3):317-34. [PubMed ID: 28186222]. https://doi.org/10.1093/bja/aex002.

  • 2.

    Mills GH. Respiratory complications of anaesthesia. Anaesthesia. 2018;73:25-33. [PubMed ID: 29313906]. https://doi.org/10.1111/anae.14137.

  • 3.

    Saraswat V. Effects of anaesthesia techniques and drugs on pulmonary function. Indian J Anaesth. 2015;59(9):557-64. [PubMed ID: 26556914]. [PubMed Central ID: PMC4613402]. https://doi.org/10.4103/0019-5049.165850.

  • 4.

    Tiefenthaler W, Pehboeck D, Hammerle E, Kavakebi P, Benzer A. Lung function after total intravenous anaesthesia or balanced anaesthesia with sevoflurane. Br J Anaesth. 2011;106(2):272-6. [PubMed ID: 21062790]. https://doi.org/10.1093/bja/aeq321.

  • 5.

    Wani KA, Dar HA, Malik AA, Chowdry NA. Comparison of postoperative pulmonary function tests after cholecystectomy performed through Kocher's incision and mini-incision. Int Surg. 2002;87(2):94-8. [PubMed ID: 12222925].

  • 6.

    Nguyen NT, Lee SL, Goldman C, Fleming N, Arango A, McFall R, et al. Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: A randomized trial. J Am Coll Surg. 2001;192(4):469-76. discussion 476-7. [PubMed ID: 11294404]. https://doi.org/10.1016/s1072-7515(01)00822-5.

  • 7.

    Coskun I, Hatipoglu AR, Topaloglu A, Yoruk Y, Yalcinkaya S, Caglar T. Laparoscopic versus open cholecystectomy: Effect on pulmonary function tests. Hepatogastroenterology. 2000;47(32):341-2. [PubMed ID: 10791184].

  • 8.

    Schwenk W, Bohm B, Witt C, Junghans T, Grundel K, Muller JM. Pulmonary function following laparoscopic or conventional colorectal resection: A randomized controlled evaluation. Arch Surg. 1999;134(1):6-12. discussion 13. [PubMed ID: 9927122]. https://doi.org/10.1001/archsurg.134.1.6.

  • 9.

    Joris J, Kaba A, Lamy M. Postoperative spirometry after laparoscopy for lower abdominal or upper abdominal surgical procedures. Br J Anaesth. 1997;79(4):422-6. [PubMed ID: 9389256]. https://doi.org/10.1093/bja/79.4.422.

  • 10.

    Gonullu NN, Cubukcu A, Alponat A. Comparison of local and general anesthesia in tension-free (Lichtenstein) hernioplasty: A prospective randomized trial. Hernia. 2002;6(1):29-32. [PubMed ID: 12090578]. https://doi.org/10.1007/s10029-002-0040-x.

  • 11.

    Zhang Q, Li Y, Xin X, Yin C, Gao F, Guo Y, et al. Effects of prone position on lung function of patients undergoing mechanical ventilation under total intravenous anesthesia. Int J Clin Exp Med. 2017;10(4):6769-74.

  • 12.

    Nielsen KG, Holte K, Kehlet H. Effects of posture on postoperative pulmonary function. Acta Anaesthesiol Scand. 2003;47(10):1270-5. [PubMed ID: 14616326]. https://doi.org/10.1046/j.1399-6576.2003.00240.x.

  • 13.

    Ebeo CT, Benotti PN, Byrd RP Jr, Elmaghraby Z, Lui J. The effect of bi-level positive airway pressure on postoperative pulmonary function following gastric surgery for obesity. Respir Med. 2002;96(9):672-6. [PubMed ID: 12243311]. https://doi.org/10.1053/rmed.2002.1357.

  • 14.

    Jepsen S, Klaerke A, Nielsen PH, Nielsen ST, Simonsen O. Systemic administration of N-acetylcysteine has no effect on postoperative lung function following elective upper laparotomy in lung healthy patients. Acta Anaesthesiol Scand. 1989;33(3):219-22. [PubMed ID: 2658458]. https://doi.org/10.1111/j.1399-6576.1989.tb02894.x.

  • 15.

    Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P, et al. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: A randomized, double-blind study. Ann Surg. 2004;240(5):892-9. [PubMed ID: 15492573]. https://doi.org/10.1097/01.sla.0000143269.96649.3b.

  • 16.

    Natalini G, Franceschetti ME, Pletti C, Recupero D, Lanza G, Bernardini A. Impact of laryngeal mask airway and tracheal tube on pulmonary function during the early postoperative period. Acta Anaesthesiol Scand. 2002;46(5):525-8. [PubMed ID: 12027846]. https://doi.org/10.1034/j.1399-6576.2002.460509.x.

  • 17.

    Cattano D, Gomez-Rivera F, Seitan C, Altamirano A, Patel C. Post-operative effects: Comparison of total intravenous and inhalational anesthesia. J Anesth Clin Res. 2012;1(S7). https://doi.org/10.4172/2155-6148.s7-003.

  • 18.

    Qiu Q, Choi SW, Wong SS, Irwin MG, Cheung CW. Effects of intra-operative maintenance of general anaesthesia with propofol on postoperative pain outcomes - a systematic review and meta-analysis. Anaesthesia. 2016;71(10):1222-33. [PubMed ID: 27506326]. https://doi.org/10.1111/anae.13578.

  • 19.

    Li C, Yan W, Shen JT, Wen SH, Liu KX. Effects of sevoflurane and propofol on intestinal ischemic reperfusion injury in patients undergoing elective open infrarenal abdominal aortic aneurysm repair: A randomized controlled trial. J Anesth Perioperat Med. 2015;2(3):126-35. https://doi.org/10.24015/japm.2015.0018.

  • 20.

    Miller TE, Gan TJ. Total intravenous anesthesia and anesthetic outcomes. J Cardiothorac Vasc Anesth. 2015;29 Suppl 1:S11-5. [PubMed ID: 26025040]. https://doi.org/10.1053/j.jvca.2015.01.022.

  • 21.

    Wang G, Liu J, Gao J, Zheng X. Comparison of the effects of sevoflurane and propofol anesthesia on pulmonary function, MMP-9 and postoperative cognition in patients receiving lung cancer resection. Oncol Lett. 2019;17(3):3399-405. [PubMed ID: 30867776]. [PubMed Central ID: PMC6396185]. https://doi.org/10.3892/ol.2019.9993.

  • 22.

    Sorour K, Vyas P, Raval D, Donovan L, Vyas A. Successful treatment of severe asthma exacerbation with sevoflurane inhalation in the intensive care unit. J Anesth Crit Care Open Access. 2015;3(2). https://doi.org/10.15406/jaccoa.2015.03.00092.

  • 23.

    Erturk E, Topaloglu S, Dohman D, Kutanis D, Besir A, Demirci Y, et al. The comparison of the effects of sevoflurane inhalation anesthesia and intravenous propofol anesthesia on oxidative stress in one lung ventilation. Biomed Res Int. 2014;2014:360936. [PubMed ID: 24527444]. [PubMed Central ID: PMC3909970]. https://doi.org/10.1155/2014/360936.

  • 24.

    Rezaiguia-Delclaux S, Jayr C, Luo DF, Saidi NE, Meignan M, Duvaldestin P. Halothane and isoflurane decrease alveolar epithelial fluid clearance in rats. Anesthesiology. 1998;88(3):751-60. [PubMed ID: 9523820]. https://doi.org/10.1097/00000542-199803000-00027.

  • 25.

    Molliex S, Crestani B, Dureuil B, Bastin J, Rolland C, Aubier M, et al. Effects of halothane on surfactant biosynthesis by rat alveolar type II cells in primary culture. Anesthesiology. 1994;81(3):668-76. [PubMed ID: 8092514]. https://doi.org/10.1097/00000542-199409000-00021.

  • 26.

    Mesnil M, Capdevila X, Bringuier S, Trine PO, Falquet Y, Charbit J, et al. Long-term sedation in intensive care unit: A randomized comparison between inhaled sevoflurane and intravenous propofol or midazolam. Intensive Care Med. 2011;37(6):933-41. [PubMed ID: 21445642]. https://doi.org/10.1007/s00134-011-2187-3.

  • 27.

    Cho YJ, Kim TK, Hong DM, Seo JH, Bahk JH, Jeon Y. Effect of desflurane-remifentanil vs. Propofol-remifentanil anesthesia on arterial oxygenation during one-lung ventilation for thoracoscopic surgery: A prospective randomized trial. BMC Anesthesiol. 2017;17(1):9. [PubMed ID: 28100177]. [PubMed Central ID: PMC5242054]. https://doi.org/10.1186/s12871-017-0302-x.

  • 28.

    von Ungern-Sternberg BS, Regli A, Schneider MC, Kunz F, Reber A. Effect of obesity and site of surgery on perioperative lung volumes. Br J Anaesth. 2004;92(2):202-7. [PubMed ID: 14722169]. https://doi.org/10.1093/bja/aeh046.

  • 29.

    Zhang XJ, Yu G, Wen XH, Lin ZC, Yang FQ, Zheng ZG, et al. Effect of propofol on twitch diaphragmatic pressure evoked by cervical magnetic stimulation in patients. Br J Anaesth. 2009;102(1):61-4. [PubMed ID: 19022792]. https://doi.org/10.1093/bja/aen327.

  • 30.

    Hedenstierna G, Tokics L, Lundquist H, Andersson T, Strandberg A, Brismar B. Phrenic nerve stimulation during halothane anesthesia. Effects of atelectasis. Anesthesiology. 1994;80(4):751-60. [PubMed ID: 8024128]. https://doi.org/10.1097/00000542-199404000-00006.

  • 31.

    Magnusson L, Tenling A, Lemoine R, Hogman M, Tyden H, Hedenstierna G. The safety of one, or repeated, vital capacity maneuvers during general anesthesia. Anesth Analg. 2000;91(3):702-7. [PubMed ID: 10960404]. https://doi.org/10.1097/00000539-200009000-00039.

  • 32.

    Rothen HU, Sporre B, Engberg G, Wegenius G, Reber A, Hedenstierna G. Prevention of atelectasis during general anaesthesia. The Lancet. 1995;345(8962):1387-91. [PubMed ID: 7760608]. https://doi.org/10.1016/s0140-6736(95)92595-3.

  • 33.

    Kim YS, Lim BG, Kim H, Kong MH, Lee IO. Effects of propofol or desflurane on post-operative spirometry in elderly after knee surgery: A double-blind randomised study. Acta Anaesthesiol Scand. 2015;59(6):788-95. [PubMed ID: 25736101]. https://doi.org/10.1111/aas.12494.