|Year : 2014 | Volume
| Issue : 2 | Page : 134-137
Remifentanil/propofol total intravenous anesthesia versus remifentanil/isoflurane inhalation anesthesia for controlled hypotension in lumbar spine fixation surgery
Hannaa F Salama
Department of Anesthesia, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
|Date of Submission||10-Oct-2013|
|Date of Acceptance||05-Dec-2013|
|Date of Web Publication||31-May-2014|
Hannaa F Salama
Department of Anesthesia, Faculty of Medicine, Al-Azhar University, Cairo
Source of Support: None, Conflict of Interest: None
The aim of the present study was to design a trial to improve the control of bleeding during spine surgery by controlled hypotension achieved through maintenance of anesthesia using remifentanil with either propofol infusion or isoflurane inhalation.
Patients and methods
The study included 40 patients assigned for lumbar spine fixation surgery (two levels). Patients were randomly allocated into two equal groups to receive either remifentanil infusion and total intravenous anesthesia with propofol (group I) or remifentanil infusion with isoflurane inhalation anesthesia (group II). The infusion rate of propofol and MAC of isoflurane were adapted to maintain mean arterial pressure in a range of 60-70 mmHg and the heart rate at about 70 beats/min. We compared the amount of intraoperative blood loss, the need for blood transfusion, duration of operation, and surgeon's satisfaction of a bloodless field between both groups.
There was no statistically significant difference between both groups in operation time (P = 0.2). The amount of intraoperative blood loss in group I was significantly lower compared with group II (P = 0.002). The total bleeding score in group I was significantly lower compared with group II (P = 0.018). Eleven patients required blood transfusion with significantly higher frequency of blood transfusion in group II [nine patients (45%)] than [two patients (10%)] in group I (P = 0.033). Mean total surgeon satisfaction score in group I was significantly higher compared with group II (P = 0.014).
Propofol/remifentanil intravenous anesthesia for spinal fixation surgery is beneficial, allowing properly controlled hypotension, minimized intraoperative bleeding, decreased need for blood transfusion, and improved surgical field visibility, compared with isoflurane/remifentanil anesthesia.
Keywords: Controlled hypotension, isoflurane, lumbar spine fixation surgery, propofol, remifentanil
|How to cite this article:|
Salama HF. Remifentanil/propofol total intravenous anesthesia versus remifentanil/isoflurane inhalation anesthesia for controlled hypotension in lumbar spine fixation surgery. Ain-Shams J Anaesthesiol 2014;7:134-7
|How to cite this URL:|
Salama HF. Remifentanil/propofol total intravenous anesthesia versus remifentanil/isoflurane inhalation anesthesia for controlled hypotension in lumbar spine fixation surgery. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Apr 11];7:134-7. Available from: http://www.asja.eg.net/text.asp?2014/7/2/134/133346
| Introduction|| |
Spinal fixation surgery is often associated with major blood loss, which is sometimes significant, requiring transfusion of blood or blood products . Blood loss varies in volume depending on the type of surgery and underlying pathology, patient's body weight, and the impact of raised intra-abdominal pressure in the prone position on the amount and pressure of venous return .
Decrease in bleeding is important to maintain a patient's hemodynamic stability and improve the surgical field. In spine surgery, the latter aspect is especially important because of the vicinity of major and highly fragile neurological structures; in addition, the surgeon's comfort shortens the operating time, which further decreases bleeding . Decrease in bleeding also reduces the need for blood transfusion with its associated complications and the increase in consumption of financial resources .
Numerous interventions are performed with general anesthesia aiming at reduction in intraoperative bleeding and improvement of field visibility. Hypotensive anesthesia is one modality for control of and reduction in bleeding during surgery. The state of 'hypotension' was achieved by reducing the peripheral blood vessel resistance, reducing the heart volume per minute, and by intercoordinating these two effects. Most frequently, peripheral vasodilators, β-blockers, and volatile anesthetics are used to cause induced hypotension ,,.
The most recent satisfactory technique is a combination treatment of remifentanil with either propofol or an inhalation agent (such as isoflurane, sevoflurane, or desflurane) .
The present study was designed as a trial to improve the control of bleeding during spine surgery by controlled hypotension achieved through maintenance of anesthesia using remifentanil with either propofol infusion or isoflurane inhalation.
| Patients and methods|| |
The study protocol was approved by the local ethical committee, and patients' written informed consent was obtained.
Forty patients belonging to American Society of Anesthesiologist (ASA) grade I and II of both genders, aged 25-60 years, undergoing lumbar spine fixation surgery of two levels in Al Zahraa University Hospital were included. They were randomly allocated into two equal groups: group I (n = 20) and group II (n = 20).
Patients with bleeding disorders, major hepatic, renal, or cardiovascular dysfunction and patients on anticoagulant therapy were excluded.
Each patient received 500 ml of Ringer's acetate solution 30 min before induction of anesthesia. For premedication, midazolam 0.05 mg/kg was given 15 min before induction of anesthesia. On arrival to the operating room, an intravenous line was sited and monitoring included pulse oximerty (SpO 2 ), noninvasive blood pressure, 5-lead ECG, and end-tidal CO 2 . After 3-min preoxygenation, induction of anesthesia was performed with fentanyl 1 μg/kg and propofol 2 mg/kg intravenous, followed by cisatracurium 0.15 mg/kg to facilitate tracheal intubation. Mechanical ventilation was adjusted to maintain end-tidal CO 2 between 35 and 40 mmHg. An infusion of remifentanil (Ultiva; GlaxoSmithKlein) was started at a rate of 0.1-1 μg/kg/min following tracheal intubation in both groups. Then, the patients were placed in the prone position. Patients were randomly allocated into two groups using computer-generated numbers.
Anesthesia was maintained with 50% oxygen in air and propofol infusion (Diprivan; AstraZeneca). The infusion started at 12 mg/kg/h and then decreased gradually to 6-10 mg/kg/h. The infusion rate was adjusted according to hemodynamic responses to maintain a mean arterial pressure (MAP) between 60 and 70 mmHg.
Anesthesia was maintained with 50% oxygen in air and isoflurane inhalation (1-2%). The concentration of isoflurane was adjusted according to hemodynamic responses to maintain MAP between 60 and 70 mmHg.
During intraoperative period, both groups received 6 ml/kg/h Ringer's acetate. Muscle relaxation was maintained with intermittent boluses of cisatracurium. The volume of intraoperative blood loss was estimated on the basis of the volume of blood in the suction bottle and the number of soaked gauze pads. The propofol, isoflurane, and remifentanil were stopped right after the termination of the surgery. At the end of surgery, residual neuromuscular blockade was reversed with 0.05 mg/kg of neostigmine and 0.02 mg/kg atropine.
All patients were operated upon by the same neurosurgical team. Data measured were intraoperative blood loss, duration of surgery, surgeon's opinion regarding the surgical field, and the need for blood transfusion.
The surgeons provided numerical assessments of the operative conditions with respect to the amount of bleeding and its effect on visibility. Surgical field was scored using the scale described by Fromme et al.  [Table 1].
Surgeon satisfaction with the field visibility was graded at the end of surgery using a five-point scoring system, with 4 denoting highly satisfactory, 3 denoting satisfactory, 2 denoting good, 1 denoting poor, and 0 denoting unsatisfactory.
Sample size was calculated using Epi Info Program (version 7) by adjusting the confidence interval to 95% and the margin of error accepted to 5% and was found to be 40 patients divided into two groups.
Data were collected, revised, coded, and entered into the statistical package for the social science (SPSS, version 17; SPSS Inc., Chicago, Illinois, USA); qualitative data were presented as number and percentages and comparison between the two groups was performed using the c2 -test, and the Fisher exact test was used only if the expected count was found less than five in any cell. The quantitative data were presented as mean and SD and comparison between the two groups was performed using the independent t-test if normal distribution and using the Mann-Whitney U-test if abnormal distribution. The confidence interval was set to 95% and the margin of error accepted was set to 5%. A P-value of less than 0.05 was considered significant.
| Results|| |
There were no statistically significant differences (P > 0.05) between both groups with respect to demographic data [Table 2].
Duration of operation showed no significant difference between both groups. Patients in group II showed significantly higher intraoperative blood loss compared with those in group I (P = 0.002). In addition, collective bleeding score for group II was significantly higher compared with group I (P = 0. 018). Eleven patients required blood transfusion in both groups, with significantly higher frequency of blood transfusion in group II [nine (45%) patients] compared with group I [two (10%) patients] (P = 0.033) [Table 3].
The mean total surgeon satisfaction score in group I was significantly higher compared with group II (P = 0.014) [Table 4]. No patients were graded as poor or unsatisfactory in both groups.
| Discussion|| |
Blood sparing in spine fixation surgery is important. Controlled hypotension is among the most widely used techniques for reducing blood loss. Remifentanil has been used successfully to induce controlled hypotension to reduce blood loss in various types of surgeries, including spine surgery ,. Remifentanil is an ultrashort-acting opioid agonist of the μ receptors. It is rapidly metabolized by specific plasma and tissue esterases. Rapid extrahepatic biotransformation to minimally active metabolites results in short and predictable duration of action, with no accumulation of effect on continuous infusion . Remifentanil decreases heart rate and MAP by its central vagotomic effect and by stimulating peripheral μ receptors, causing peripheral vasodilatation and consequent decrease in systemic vascular resistance .
In the present study, in addition to remifentanil infusion, propofol infusion (group I) or isoflurane inhalation (group II) was used for maintenance of anesthesia. It was found that the amount of intraoperative bleeding that decreases field visibility was significantly lower with propofol infusion compared with isoflurane inhalation at the same level of blood pressure. As remifentanil dose was adjusted in both groups to the same target blood pressure, it seemed that propofol reduced bleeding by another mechanism other than controlled hypotension.
Multiple experimental studies tried to explore such observation; they reported that, at clinically relevant concentrations, propofol did not influence the surface expression density of fibrinogen receptors, P-selectin molecules, and the percentage of leukocyte-platelet aggregates ex vivo, thus did not allow interruption of either platelet or coagulation functions . Dordoni et al.  found that propofol, in comparison with other anesthetics, had no effect on platelet function both ex vivo and in vitro and concluded that propofol might be considered as a hemostatically safe drug. Brookes et al.  using experimental animal model reported that, after hemorrhage, leukocyte adhesion and CD11b expression increased during thiopental anesthesia, but propofol/fentanyl and propofol/ketamine protected against hemorrhage-induced leukocyte adhesion and this anti-inflammatory effect was mediated by direct inhibition of CD11b expression on leukocytes.
Recent experimental study supported the assumed hemostatic effect of propofol; Erfourth et al.  evaluated the changes in serial hemograms and serum biochemical profiles in tumor-bearing dogs undergoing daily anesthesia with propofol as an induction agent for radiation therapy and found that leukocyte and platelet parameters did not differ significantly over time. Chung et al.  suggested that propofol at concentrations required for sedation and general anesthesia has no inhibitory effect on platelet aggregation after 3 h of incubation.
In support of the obtained results and these experimental explanations, clinical trials reported similar reduction in amount of bleeding during various surgical procedures using propofol; Albertin et al.  compared the effects of sevoflurane and propofol on lumbar-paraspinal-muscles regional blood flow, as well as on bleeding when controlled hypotension was used and found that peripheral blood flow was significantly greater in the propofol group both before and during the hypotensive period, but blood loss and intraoperative bleeding were significantly reduced when propofol had been used. They explained these findings hypothesizing a selective vasodilation by propofol (postcapillary, venous vasodilation), different from that by sevoflurane (precapillary, arteriolar vasodilation). Okuyucu et al.  evaluated the effects of anesthetic agents on hemorrhage during tonsillectomy with standardized surgical techniques and management of bleeding and found that propofol-based anesthesia significantly decreased bleeding during tonsillectomy. Vedenin et al.  reviewed 25 endotracheabronchial operations for tumor-related stenosis of the central bronchi and/or trachea using hypotensive anesthesia, which was induced and maintained using propofol, and reported that MAP was lower than in control and blood loss decreased significantly, whereas gas exchange indices significantly improved and at intubation stage increase in MAP and heart rate was avoided.
Surgeons' satisfaction score in the propofol group showed significantly higher satisfaction scores compared with inhalational anesthesia. These data are in accordance with the study by Ahn et al.  who reported that, in patients with high Lund-Mackay score, propofol/remifentanil anesthesia resulted in less blood loss and better surgical conditions for FESS than sevoflurane/remifentanil anesthesia. In addition, Baker and Baker  reported that remifentanil appears to produce better surgical conditions than other opioid analgesics, and TIVA with propofol may provide superior conditions to a volatile-based technique.
In conclusion, this study showed that propofol/remifentanil intravenous anesthesia for lumbar spinal fixation surgery is beneficial, allowing properly controlled hypotension, minimized intraoperative bleeding, and improved surgical field visibility compared with isoflurane/remifentanil anesthesia.
Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4]