|Year : 2015 | Volume
| Issue : 4 | Page : 539-546
Total intravenous anesthesia versus inhalational anesthesia for radiofrequency ablation of hepatic focal lesions: a comparative study
Mahmoud A Ghallab, Ghada M Samir MD , Dalia A Ibrahim, Rania M Hussien
Department of Anaesthesia, Critical Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
|Date of Submission||01-Nov-2014|
|Date of Acceptance||12-Mar-2015|
|Date of Web Publication||29-Dec-2015|
Ghada M Samir
Department of Anaesthesia, Critical Care and Pain Management, Embassies Area, Symphony Tower, Cairo 11471
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess whether total intravenous anesthesia (TIVA) offers an alternative anesthetic technique to inhalational anesthesia for patients undergoing radiofrequency (RF) ablation for hepatic focal lesions.
Patients and methods
A total of 100 American Society of Anesthesiologist (ASA) physical status II patients were included and divided into two groups: the first group underwent RF ablation of hepatic focal lesions under sevoflurane inhalational anesthesia with a laryngeal mask airway applied, whereas the second group was under TIVA with propofol infusion and face mask was applied. The hemodynamic changes, as well as the changes in Spo 2 , were recorded during the procedure and in the recovery room. The time to speak and the occurrence of postoperative nausea and vomiting (PONV) in the recovery room were also recorded.
The two groups were comparable as regards the changes in arterial blood pressure values from the baseline. The TIVA group showed reductions in Spo 2 values after propofol loading, which was corrected with the application of an oropharyngeal airway. The time to speak was longer in the TIVA group than in the sevoflurane group, but it did not prolong the time of discharge from the postanesthesia care unit. The sevoflurane group showed higher incidence of PONV in the recovery room.
TIVA with propofol infusion offers an alternative anesthetic technique for RF ablation of hepatic focal lesions with the advantages of hemodynamic stability, avoiding instrumentation of the airway in a day-case patient without the development of PONV with the same technical success offered by sevoflurane anesthesia.
Keywords: day case, hepatic, radiofrequency, total intravenous anesthesia
|How to cite this article:|
Ghallab MA, Samir GM, Ibrahim DA, Hussien RM. Total intravenous anesthesia versus inhalational anesthesia for radiofrequency ablation of hepatic focal lesions: a comparative study. Ain-Shams J Anaesthesiol 2015;8:539-46
|How to cite this URL:|
Ghallab MA, Samir GM, Ibrahim DA, Hussien RM. Total intravenous anesthesia versus inhalational anesthesia for radiofrequency ablation of hepatic focal lesions: a comparative study. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2020 Feb 21];8:539-46. Available from: http://www.asja.eg.net/text.asp?2015/8/4/539/172738
| Introduction|| |
Hepatic resection forms the conventional treatment for patients with hepatocellular carcinoma; however, the majority of primary liver cancers are not suitable for curative resection at the time of diagnosis  . Difficulties of surgical resection may be related to the size, site, and number of tumors, vascular and extrahepatic involvement, as well as liver functions of the patient  . There is a need to develop a simple effective technique for the treatment of unresectable tumors. Thermal ablation techniques for the treatment of malignant hepatic tumors include both freezing (cryoablation) and heating [radiofrequency (RF), microwave, laser, and high-intensity focused sonography] techniques. Interest has developed in thermal ablation techniques that produce heat  . Laser ablation has been claimed to be effective for the treatment of both hepatocellular carcinoma and colorectal metastases. However, one of the primary investigators of laser ablation in England has essentially abandoned the technique in favor of RF ablation  . Overall, the interest and enthusiasm for RF thermal ablation has far exceeded that for either microwave or laser ablation  .
Patients are considered potential candidates if they have fewer than five tumors, each less than 5 cm in diameter, and no evidence of extrahepatic tumor. In practice, patients with more than two tumors approaching 5 cm are poor candidates because of the sheer bulk of their tumor burden and the difficulty in completely ablating tumors of such size  . Ablation of tumors adjacent to the diaphragm, liver capsule, gallbladder, or main portal vessels will cause considerably more pain during and after the procedure compared with ablation of tumors embedded in the hepatic parenchyma  . Ablation of tumors adjacent to the diaphragm will cause transient right shoulder pain; however, if the diaphragm is directly ablated, the pain can be severe and last for several months  .
The RF ablation system consists of a very high-frequency (200-1200 kHz) alternating current generator, a RF needle (monopolar electrode), and a grounding pad, to which the patient must be connected. In this circuit, electric current enters through the electrode under the guidance of an imaging method, ultrasound or computerized tomography, with the patient as resistor. As the electric current alternates in directions at high frequency, tissue ions that are attempting to follow the direction of the current are agitated. Because of the natural high resistivity in the living tissue, ionic agitation produces frictional heat at the immediate vicinity of electrodes. Because the grounding pad has a very large surface area, the electrical resistance is low; hence, the production of frictional heat is concentrated at the needle electrode. Thus, deposition of electromagnetic energy from electric current produces thermal injury. It also closes small blood vessels, minimizing the risk of bleeding. The extent and nature of the thermal injury are dependent on two important factors: temperature and RF application duration. To produce irreversible cell damage, it takes only 4-5 min at 50-55°C. Temperatures between 50 and 100°C are ideal for RF ablation , .
RF ablation is better performed as an outpatient procedure. Admission to hospital is not usually necessary  . The procedure can be performed under intravenous conscious sedation or general anesthesia, depending on the patient and doctor preferences. Midazolam, propofol, and opioids are often used alone or in combination. Midazolam can be used as the sole supplement, but it can prove difficult to titrate and can lead to either undesirably deep sedation or a confused and uncooperative patient. Therefore, opioids are often used in combination with midazolam to prevent the undesirable effects of both agents, as a smaller dose of each drug will be required to maintain adequate sedation  . Propofol is the nearest to an ideal agent for sedation, because of its favorable pharmacokinetic profile, with rapid onset, easy alteration of the sedation level, and quick recovery. A dose-related sedative effect, as well as a non-dose-related anxiolysis has been demonstrated. Amnesia is proportional to the administered dose but is incomplete and less effective compared with midazolam. The analgesic properties of propofol are known to be poor  .
Patients may be unable to tolerate percutaneous RF ablation with just conscious sedation. This may be applied for cancer patients' chronic pain who have been taking routine analgesics, patients with a history of alcohol or drug abuse, or patients with a low threshold to pain  . General anesthesia may be indicated for these patients. Likewise, general anesthesia may be preferred if an ablation is going to be extensive and the procedure is expected to last 3 or more hours. Inhalational anesthetic technique can be practiced wherever a general anesthetic is given. Total intravenous anesthesia (TIVA) with propofol is a technique that is gaining tremendous popularity , . This study was designed to assess the hemodynamic stability offered by TIVA using propofol infusion with decreased incidence of postoperative nausea and vomiting (PONV) and the same technical success offered by inhalational anesthesia.
| Patients and methods|| |
After obtaining the approval of Ain-Shams University Hospitals and Dar Elhekma Hospital ethical committees, informed consent was taken from 100 patients of ASA physical status I or II, aged 40-70 years, scheduled to undergo RF ablation of hepatic focal lesions in this randomized controlled study at Dar Elhekma and Ain Shams University Hospitals, from January until December 2014. Patients known to have undergone redo RF, presence of chest infection, history of severe bronchial asthma, mental retardation or psychiatric disorders, severely jaundiced patients, and patients of ASA physical status III or IV were excluded from the study.
Patients were divided on the basis of the anesthetic technique into two equal groups of 50 patients each:
Group 1 patients received TIVA. After application of oxygen at 4 l/min through a face mask, 1 mg/kg propofol (propofol 1% fresenius kabi; Austria GmbH Graz, Granz, Austria) and 10 mg nalbuphine (nalbuphine hydrochloride 20 mg/2 ml; SERB S.A.S., Paris, France) were given intravenously, followed by maintenance of anesthesia with propofol infusion scale (multistep infusion regimen) − 10 mg/kg/h for the first 10 min, 8 mg/kg/h for the second 10 min, and 6 mg/kg/h for the remaining time.
Group 2 patients received general anesthesia with sevoflurane (Abbott). Anesthesia was induced with 1 mg/kg propofol IV (propofol 1% fresenius kabi; Austria GmbH Graz), 10 mg nalbuphine IV (nalbuphine hydrochloride 20 mg/2 ml; SERB S.A.S.), and 0.5 mg/kg atracurium (atracurium, Tracrium, 25 mg/2.5 ml; GlaxosmithKline, GSK) and then a laryngeal mask was applied; anesthesia was maintained with 2% sevoflurane and 0.1 mg/kg atracurium every 30 min until the end of the procedure.
For both groups, 1 mg granitryl IV (granisetron 1 mg/ml; Alex.co in Egy-pharma), 50 mg voltaren IV infusion (diclofenac, 75 mg/3 ml; Novartis). 100 mg (5 ml) lignocaine (Sigma-Tec Pharmaceutical Idust-A.R.E.) was given by the surgeon through the needle insertion site.
Anesthetic technique: On arriving to the operating theater, patients had an 18-G intravenous cannula inserted and infusion of Ringer's solution was started. Intraoperative basic monitors were applied using three-lead ECG, pulse oximetry, capnography, and NIBP (Dash 5000; General Electric, Medical Systems Information Technologies, Inc. Tower Ave., Milwaukee, WI, USA). The anesthetic machine used was Datex-Ohmeda, Inc. 3030 Ohmeda Drive, Madison, WI 53707-7550, USA.
Hemodynamic parameters (heart rate, systolic blood pressure, and oxygen saturation) were recorded before induction, at 10-min intervals, and postoperatively at the postanesthesia care unit (PACU); administration of any additional bolus of propofol, along with the time and reason of administration, was recorded. PONV, time to speak, postoperative pain, and technical success were also recorded.
The required sample size was calculated using the G Power software (Heinrich Heine Universität, Düsseldorf, Germany). It was estimated that a sample of 50 patients in either study group would achieve a power of 84% to detect an effect size (Cohen's d) of 0.6 as regards the difference in hemodynamic variables and oxygen saturation between the two study groups.
Statistical analysis was carried out using MedCalc©, version 12.5 (MedCalc© Software bvba, Ostend, Belgium). The D'Agostino-Pearson test was used to test the normality of numerical data distribution. Normally distributed numerical data were presented as mean and SD and intergroup differences were compared with the independent-samples t-test. Repeated-measures analysis of variance was used for within-group comparison of serial measurements. Qualitative data were presented as number and percentage and Fisher's exact test was applied for comparison of the two groups.
A P-value less than 0.05 was considered statistically significant.
| Results|| |
A total of 100 patients were enrolled in the study and were divided into two groups of 50 patients each. The two groups were comparable as regards the age of the patients and the duration of the procedure, as shown in [Table 1].
In group 2, the baseline heart rate, as well as that recorded at 10 min, 20 min, and in the PACU, was higher than that recorded at the same time intervals in group 1. Although these were statistically significant results, they were clinically nonsignificant; the mean ± SD was 74.1 ± 12.4, 75 ± 9.2, and 79.1 ± 9, respectively, in group 2 and 69.5 ± 9.5, 67.8 ± 8.6, and 74.5 ± 9.9 beats/min, respectively, in group 1 [Table 2]. The change in heart rate at 10, 20, and 30 min in group 1 was significantly lower than that at the baseline both statistically and clinically, as the diff of 4.0 and 95% CI of 1.4-6.6 and diff of 5.8 and 95% CI of 3.4-8.2 and diff of 3.4 and 95% CI of 1.3-5.547, respectively. In group 2, the change in heart rate at 10 and 30 min was also significantly lower than that at the baseline statistically and clinically, as the diff was 2.7 with 95% CI of 0.2-5.3 and diff of 3.6 and 95% CI of 0.3-6.9, respectively [Table 3].
The changes in the systolic and diastolic blood pressures were statistically nonsignificant at the determined study times between the two groups [Table 4] and [Table 5]. There was a statistically significant lowering of systolic blood pressure, compared with baseline measure at 10 [diff of 19.5 and 95% confidence interval (CI) of 13.0-25.9], 20 (diff of 14.9 and 95% CI of 6.3-23.5), and 30 (diff of 7.5 and 95% CI of 2.1-12.8) min from induction in group 1, with all P-values less than 0.05. Moreover, there was a statistically significant lowering of systolic blood pressure, compared with baseline measure at 10 (diff of 23.1 and 95% CI of 16.7-29.6), 20 (diff of 19.1 and 95% CI of 14.9-23.2), and 30 (diff of 11.3 and 95% CI of 4.8-17.9) minutes from induction in group 2, with all P-values less than 0.05 [Table 6]. There was a statistically significant lowering of diastolic blood pressure, compared with baseline measure at 10 (diff of 8.5 and 95% CI of 4.1-12.8) and 20 (diff of 6.4 and 95% CI of 0.1-12.7) min from induction in group 1, with all P-values less than 0.05. Moreover, there was a statistically significant lowering of diastolic blood pressure, compared with baseline measure at 10 (diff of 13.8 and 95% CI of 9.0-18.7) and 20 (diff of 8.8 and 95% CI of 5.0-12.7) min from induction in group 2, with all P-values less than 0.05 [Table 7].
The SpO 2 decreased at 10, 20, and 30 min from the baseline in group 2 [Figure 1].
|Figure 1: Mean arterial oxygen saturation (SpO2) changes in both study groups. Error bars represent standard error of the me an (SEM)|
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The time to speak was longer in group 2 than in group 1, with a mean ± SD of 16.3 ± 3.6 vs. 7.3 ± 3.7, respectively, and this difference was statistically significant [Figure 2].
|Figure 2: Mean time to speak in both study groups. Error bars represent standard error of the me an (SEM)|
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A total of 13 patients in group 1 developed postoperative nausea only, with no vomiting. However, no patient in group 2 developed either postoperative nausea or vomiting [Figure 3].
|Figure 3: Incidence of postoperative nausea and vomiting (PONV) in both study groups|
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| Discussion|| |
In our study, the heart rate and systolic and diastolic pressures decreased over time in both groups, indicating the anesthetic and analgesic efficacy of both techniques and the vasodilator effect of propofol. In the study conducted by Pitton and colleagues in 2003  , the mean heart rate increased by 8.12 beats/min from the baseline, and the mean rise in systolic blood pressure was 5.38% from the baseline in patients under general anesthesia during the passage of the RF current  . Despite this, the changes were also clinically nonsignificant as they were less than 20%. TIVA with propofol helped to avoid sympathetic stimulation and maintain hemodynamic stability during the procedure in a way comparable to that offered by sevoflurane anesthesia. It offered the added benefit of avoiding insertion of a laryngeal mask airway with muscle relaxant in a day-case procedure.
In our study, the SpO 2 decreased from the baseline over time in group 2. Although this decrease was statistically significant, it was clinically corrected by applying head-tilt and chin-lift maneuver. Only five patients required insertion of an oropharyngeal airway and no patient needed to change to general anesthesia due to rapid desaturation or respiratory standstill. In 1997, Hall and colleagues and, in 2000, Joo and Perks reported that the incidence of apnea was higher (65%) and the time to settled respiration was longer (126 vs. 94 s) with propofol induction , .
Increased incidence of bradycardia as well as decrease in arterial pressure and ventilatory response was reported in the study conducted by Nieuwenhuijs et al.  in 2000 at infusion rates of propofol 100-200 mg/h. Hemodynamic changes occurred more often in the propofol group. The change in heart rate and blood pressure by 20% during passage of RF current that was seen under conscious sedation was not seen under general anesthesia in the study conducted by Lauwers et al.  in 1998. This was attributable to the attenuation of the noxious stimulus under general anesthesia.
In our study, no patient in the TIVA group needed to change to general anesthesia with the need to secure the airway with LMA or endotracheal intubation due to uncorrected desaturation or intolerable pain. In the study conducted by Chakravorty and colleagues in 2006, eight patients underwent the procedure under sedation analgesia comfortably, 16 had to be converted to general anesthesia mid procedure. The chief causes of conversion to general anesthesia were pain (56.25%), respiratory standstill, and controlled apnea during lesion location (18.75%), to prevent injury to the diaphragm or pleura (12.5%) and in pancreatic lesions (12.5%). They concluded that index tumors less than 3 cm in size and situated away from the diaphragm could be ablated completely under sedation. The index tumors measuring 3-5 cm had a higher incidence of incomplete ablation under sedation analgesia, as compared with the general anesthesia group (45.45 vs. 15.9%)  .
PONV is one of the most frequent side effects of general anesthesia. PONV, for years, has been called and remains the big little problem. In our study, patients in the TIVA group developed neither postoperative nausea nor postoperative vomiting. A total of 13 patients in the sevoflurane group developed postoperative nausea only, with no vomiting. Granisetrone 1 mg was given intravenously in the PACU. Apfel et al.  concluded that the proemetogenic effect of volatile anesthetics must be considered the main cause of PONV in the early postoperative period (0-2 h). The incidence of nausea and vomiting after propofol infusion is generally low and an antiemetic effect has been suggested  . The incidence of postoperative nausea was found to be reduced after total intravenous compared with inhalation anesthesia. Antagonism of the dopamine D2 receptor by propofol has recently been suggested as a possible mechanism for this effect  . In 2001, Visser and colleagues observed that TIVA using propofol resulted in a clinically relevant reduction of PONV compared with isoflurane anesthesia. PONV can cause a prolonged PACU stay, patient discomfort, and serious complications such as aspiration, electrolyte imbalance, and increased bleeding, thereby increasing medical costs  .
In 1997, Raeder et al.  reported a greater incidence of PONV in sevoflurane-maintained patients as compared with propofol-maintained patients (32 vs. 18%, respectively); however, the number of patients requiring antiemetic therapy was similar. When used as an induction agent only, propofol is not protective against PONV, probably because of its short duration of action  . Propofol TIVA was associated with a reduced incidence of PONV compared with isoflurane anesthesia (29% after TIVA vs. 47% after isoflurane). Several studies have reported that the use of propofol TIVA is associated with a lower incidence of PONV as compared with the inhaled anesthetic technique  .
Ambulatory surgery continues to grow and thrive such that the vast majority (65-70%) of all surgical procedures are performed on an outpatient basis. Expeditious recovery and shorter hospital stays are necessary to improve the efficiency of an ambulatory facility and reduce healthcare costs. One of the major factors that determine the speed of recovery from anesthesia is the choice of anesthetic technique. Although local and regional anesthesia techniques are increasingly used in the ambulatory setting because they allow a more rapid recovery, general anesthesia is still the most common anesthetic technique. An ideal general anesthetic technique should provide smooth and rapid induction, optimal operating conditions, and rapid recovery with minimal or no side effects. The shorter-acting inhaled anesthetics (sevoflurane) offer the potential for rapid recovery from anesthesia. However, with the introduction of propofol and newer delivery systems (e.g. target-controlled infusion), there is an increased interest in TIVA  .
In our study, in the TIVA group, as there was no instrumentation of the airway and the patients were spontaneously breathing, they were transferred to the PACU, monitored until they speak, and the operating room (OR) turnover was preserved. However, in the sevoflurane group, the laryngeal mask airway (LMA) was removed when full motor power regained and neostigmine and atropine were given to completely reverse the motor block and the patient was able to talk in the OR. In 1997, Hall et al.  reported that the time to emergence (eye opening to command) was shorter in patients with sevoflurane maintenance (5.2 min) versus (7 min) that for propofol induction and sevoflurane maintenance. It is believed that the inhaled anesthetic technique allows rapid emergence from anesthesia, probably because of the bioavailability of sevoflurane, ease of titratibility, and exertion of some neuromuscular blocking effect, which may reduce the requirements of nondepolarizing muscle relaxants  . The avoidance of muscle relaxants may facilitate recovery, because even a minor degree of residual blockade (usually not appreciated clinically) could cause distressing symptoms such as visual disturbances, inability to sit up without assistance, facial weakness, and generalized weakness that may delay recovery  .
Recovery from anesthesia is faster with sevoflurane than with propofol, although it does not translate into an earlier discharge from the PACU and there was no difference in the time taken for the patient to be ready for discharge , . In 1998, Song et al.  reported the fast-track eligibility of sevoflurane and propofol (75 and 26%, respectively). Although the duration of PACU stay in outpatients was slightly lower with TIVA (median 150 vs. 160 min after isoflurane), the duration of hospitalization was similar between the groups  .
Postprocedural pain was similar between the two groups and no patient required rescue analgesia in the PACU. Technical success was also similar in both groups.
| Conclusion|| |
Intraoperative comfort and patient satisfaction during RF ablation of hepatic focal lesions can be improved with the use of TIVA with good hemodynamic control and minimal incidence of complications such as apnea, pain, or PONV. The anesthetic techniques have to be modified on the basis of the site, size, and number of lesions, so as to provide maximum patient comfort and ensure technical success.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]