Evaluation of Quality of Recovery With Quality of Recovery-15 Score After Closed-Loop Anesthesia Delivery System-Guided Propofol Versus Desflurane General Anesthesia in Patients Undergoing Transabdominal Robotic Surgery: A Randomized Controlled Study.

BACKGROUND: Robotic technique of surgery allows surgeons to perform complex procedures in difficult-to-access areas of the abdominal/pelvic cavity (eg, radical prostatectomy and radical hysterectomy) with improved access and precision approach. At the same time, automated techniques efficiently deliver propofol total intravenous anesthesia (TIVA) with lower anesthetic consumption. As both above are likely to bring benefit to the patients, it is imperative to explore their effect on postanesthesia recovery. Quality of Recovery-15 (QoR-15) is a comprehensive patient-reported measure of the quality of postanesthesia recovery and assesses compendious patients' experiences (physical and mental well-being). This randomized study assessed the effect of automated propofol TIVA versus inhaled desflurane anesthesia on postoperative quality of recovery using the QoR-15 questionnaire in patients undergoing elective robotic surgery. METHODS: One hundred twenty patients undergoing robotic abdominal surgery under general anesthesia (GA) were randomly allocated to receive propofol TIVA administered by closed-loop anesthesia delivery system (CLADS) (CLADS group) or desflurane GA (desflurane group). Postoperative QoR-15 score on postoperative day 1 (POD-1) and postoperative day 2 (POD-2) (primary outcome variables), individual QoR-15 item scores (15 nos.), intraoperative hemodynamics (heart rate, mean blood pressure), anesthesia depth consistency, anesthesia delivery system performance, early recovery from anesthesia (time-to-eye-opening, and time to tracheal extubation), and postoperative adverse events (sedation, postoperative nausea and vomiting [PONV], pain, intraoperative awareness recall) (secondary outcome variables) were analyzed. RESULTS: On POD-1, the CLADS group scored significantly higher than the desflurane group in terms of "overall" QoR-15 score (QoR-15 score: 114.5 ± 13 vs 102.1 ± 20.4; P = .001) and 3 individual QoR-15 "items" scores ("feeling rested" 7.5 ± 1.9 vs 6.4 ± 2.2, P = .007; "good sleep" 7.8 ± 1.9 vs 6.6 ± 2.7, P = .027; and "feeling comfortable and in control" 8.1 ± 1.7 vs 6.9 ± 2.4, P = .006). On the POD-2, the CLADS group significantly outscored the desflurane group with respect to the "overall" QoR-15 score (126.0 ± 13.6 vs 116.3 ± 20.3; P = .011) and on "5" individual QoR-15 items ("feeling rested" 8.1 ± 1.4 vs 7.0 ± 2.0, P = .003; "able to return to work or usual home activities" 6.0 ± 2.2 vs 4.6 ± 2.6, P = .008; "feeling comfortable and in control" 8.6 ± 1.2 vs 7.7 ± 1.9, P = .004; "feeling of general well-being" 7.8 ± 1.6 vs 6.9 ± 2.0, P = .042; and "severe pain" 9.0 ± 1.9 vs 8.1 ± 2.5, P = .042). CONCLUSIONS: Automated propofol TIVA administered by CLADS is superior to desflurane inhalation GA with respect to early postoperative recovery as comprehensively assessed on the QoR-15 scoring system. The effect of combined automated precision anesthesia and surgery (robotics) techniques on postoperative recovery may be explored further.

Evaluation of Automated Delivery of Propofol Using a Closed-Loop Anesthesia Delivery System in Patients Undergoing Thoracic Surgery: A Randomized Controlled Study.

OBJECTIVE: Automated propofol total intravenous anesthesia (TIVA) administered by a closed-loop anesthesia delivery system (CLADS) exhibits greater efficiency than conventional manual methods, but its use in major thoracic surgery is limited. DESIGN: Prospective, single-blind, randomized controlled study. SETTING: Single-center tertiary care hospital. PARTICIPANTS: Patients undergoing thoracic surgery. INTERVENTIONS: Patients were randomly allocated to receive CLADS-driven (CLADS group) or manually controlled (manual group) propofol TIVA. MEASUREMENTS AND MAIN RESULTS: Anesthesia depth consistency (primary objective) and anesthesia delivery performance, propofol usage, work ergonomics, intraoperative hemodynamics, and recovery profile (secondary objectives) were analyzed. No differences were found for anesthesia depth consistency (percentage of time the bispectral index was within ± 10 of target) (CLADS group: 82.5% [78.5%-87.2%] v manual group: 86.5% [74.2%-92.5%]; p = 0.581) and delivery performance, including median performance error (CLADS group: 3 [-4 to 6] v manual group: 1 [-2.5 to 6]); median absolute performance error (CLADS group: 10 [10-12] v manual group:10 [8-12]); wobble (CLADS group: 10 [8-12] v manual group: 9 [6-10.5]); and global score (CLADS group: 24.2 [21.2-29.3] v manual group: 22.1 [17.3-32.3]) (p > 0.05). However, propofol requirements were significantly lower in the CLADS group for induction (CLADS group: 1.27 ± 0.21] mg/kg v manual group: 1.78 ± 0.51 mg/kg; p = 0.014) and maintenance (CLADS group: 4.02 ± 0.99 mg/kg/h v manual group: 5.11 ± 1.40 mg/kg/h; p = 0.025) of TIVA. Ergonomically, CLADS-driven TIVA was found to be significantly superior to manual control (infusion adjustment frequency/h) (manual infusion: 9.6 [7.8-14.9] v CLADS delivery [none]). CONCLUSIONS: In thoracic surgery patients, CLADS-automated propofol TIVA confers significant ergonomic advantage along with lower propofol usage.

The impact of tracheal-tube introducer guided intubation in anticipated non-difficult airway on postoperative sore throat: a randomized controlled trial.

BACKGROUND: The passage of tube across the glottis-inlet being the significant "active" component of intubation, associating postoperative sore throat (POST) with "passive" presence of high-volume low-pressure tracheal-tube cuff is unjustified. Tracheal-tube introducers (TTI), commonly employed to facilitate tracheal intubation during difficult airway management, can influence intubation quality and decrease incidence of POST. METHODS: Four hundred and fifty patients undergoing laparoscopic/open surgery were randomly allocated to receive conventional intubation (non-TTI group, N.=150) or intubation facilitated with rigid-TTI (rigid-TTI group, N.=150) or non-rigid TTI (non-rigid TTI group, N.=150). This study analyzed effects of conventional versus TTI-guided intubation on reducing the incidence of POST (primary objective); intubation profile (time, attempts, response), and complications (trauma, inspiratory stridor) (secondary objectives). RESULTS: Four hundred and twenty patients completed the study. The incidence of POST was lowest in patients of rigid-TTI group (N.=40, 29.0%); which was significantly lower than the non-TTI group (N.=64, 45.1%) (P=0.005) but comparable to the non-Rigid-TTI group (N.=53, 37.9%, P=0.117). In addition, the incidence of POST in rigid-TTI group was significantly lower than those in the non-TTI group at 2-hour (rigid-TTI group: N.=19, 13.8%; non-TTI group: N.=41, 28.9%, P=0.002) and 4-hour (rigid-TTI group: N.=23, 16.7%; non-TTI group: N.=43, 30.3%, P=0.007) time points. No difference was found in the incidence of airway management related morbidity, including, laryngospasm and inspiratory stridor in the three groups. CONCLUSIONS: Rigid-TTI by its ability to positively modify friction dynamics between glottis-inlet and the passing tracheal-tube; has the potential to improve quality of intubation and decrease the incidence of POST.

The Effect of Dexmedetomidine on Propofol Requirements During Anesthesia Administered by Bispectral Index-Guided Closed-Loop Anesthesia Delivery System: A Randomized Controlled Study.

BACKGROUND: Dexmedetomidine, a selective α2-adrenergic agonist currently approved for continuous intensive care unit sedation, is being widely evaluated for its role as a potential anesthetic. The closed-loop anesthesia delivery system (CLADS) is a method to automatically administer propofol total intravenous anesthesia using bi-spectral index (BIS) feedback and attain general anesthesia (GA) steady state with greater consistency. This study assessed whether dexmedetomidine is effective in further lowering the propofol requirements for total intravenous anesthesia facilitated by CLADS. METHODS: After ethics committee approval and written informed consent, 80 patients undergoing elective major laparoscopic/robotic surgery were randomly allocated to receive GA with propofol CLADS with or without the addition of dexmedetomidine. Quantitative reduction of propofol and quality of depth-of-anesthesia (primary objectives), intraoperative hemodynamics, incidence of postoperative adverse events (sedation, analgesia, nausea, and vomiting), and intraoperative awareness recall (secondary objectives) were analyzed. RESULTS: There was a statistically significant lowering of propofol requirement (by 15%) in the dexmedetomidine group for induction of anesthesia (dexmedetomidine group: mean ± standard deviation 0.91 ± 0.26 mg/kg; nondexmedetomidine group: 1.07 ± 0.23 mg/kg, mean difference: 0.163, 95% CI, 0.04-0.28; P = .01) and maintenance of GA (dexmedetomidine group: 3.25 ± 0.97 mg/kg/h; nondexmedetomidine group: 4.57 ± 1.21 mg/kg/h, mean difference: 1.32, 95% CI, 0.78-1.85; P < .001). The median performance error of BIS control, a measure of bias, was significantly lower in dexmedetomidine group (1% [-5.8%, 8%]) versus nondexmedetomidine group (8% [2%, 12%]; P = .002). No difference was found for anesthesia depth consistency parameters, including percentage of time BIS within ±10 of target (dexmedetomidine group: 79.5 [72.5, 85.3]; nondexmedetomidine group: 81 [68, 88]; P = .534), median absolute performance error (dexmedetomidine group: 12% [10%, 14%]; nondexmedetomidine group: 12% [10%, 14%]; P = .777), wobble (dexmedetomidine group: 10% [8%, 10%]; nondexmedetomidine group: 8% [6%, 10%]; P = .080), and global score (dexmedetomidine group: 25.2 [23.1, 35.8]; nondexmedetomidine group: 24.7 [20, 38.1]; P = .387). Similarly, there was no difference between the groups for percentage of time intraoperative heart rate and mean arterial pressure remained within 20% of baseline. However, addition of dexmedetomidine to CLADS propofol increased the incidence of significant bradycardia (dexmedetomidine group: 14 [41.1%]; nondexmedetomidine group: 3 [9.1%]; P = .004), hypotension (dexmedetomidine group: 9 [26.5%]; nondexmedetomidine group: 2 [6.1%]; P = .045), and early postoperative sedation. CONCLUSIONS: The addition of dexmedetomidine to propofol administered by CLADS was associated with a consistent depth of anesthesia along with a significant decrease in propofol requirements, albeit with an incidence of hemodynamic depression and early postoperative sedation.