Desflurane Anesthesia Compared with TIVA on ACT in Strabismus Surgery

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Desflurane Anesthesia Compared with Total Intravenous Anesthesia on Anesthesia-Controlled Operating Room Time in Ambulatory Surgery Following Strabotomy: A Randomized Controlled Study

Ophthalmic ambulatory surgery, particularly strabismus correction, increasingly favors general anesthesia to enhance patient comfort and procedural efficiency. The choice between total intravenous anesthesia (TIVA) and inhalational anesthesia often hinges on their impact on anesthesia-controlled time (ACT), which includes induction, extubation, and operating room (OR) exit times. ACT directly influences OR turnover and overall efficiency, a critical factor in high-volume centers performing thousands of strabismus surgeries annually. This study compares desflurane-based inhalational anesthesia (DES) with propofol-remifentanil TIVA in strabismus surgery, focusing on ACT components, hemodynamic stability, and post-operative outcomes.

Study Design and Population

This prospective, randomized, single-blind trial enrolled 200 ASA physical status I–II patients aged 18–60 years undergoing elective strabismus surgery at Zhongshan Ophthalmic Center. Exclusion criteria included obesity (BMI >30 kg/m²), cardiopulmonary comorbidities, drug allergies, chronic pain, or refusal to participate. Participants were randomized 1:1 to DES (n=100) or TIVA (n=100). Anesthesia providers were unblinded, but patients, outcome assessors, and statisticians remained blinded.

Anesthesia Protocols

Induction was standardized for both groups: propofol (2 mg/kg), fentanyl (1 μg/kg), and cisatracurium (0.1 mg/kg) facilitated laryngeal mask airway (LMA) insertion. Pre-emptive analgesia and antiemetics included flurbiprofen axetil (100 mg), dexamethasone (5 mg), and palonosetron (250 μg).

Maintenance:

  • TIVA Group: Propofol (effect-site concentration: 2.0–4.0 μg/mL) and remifentanil (0.15 μg·kg⁻¹·min⁻¹) via target-controlled infusion.
  • DES Group: Desflurane (6–8 vol%) in 100% oxygen (2 L/min).

Bispectral index (BIS) values (45–55) guided anesthetic depth. Ventilation maintained end-tidal CO₂ at 35–40 mmHg. Intraoperative hypotension (SBP <90 mmHg), bradycardia (HR <50 bpm), and oculocardiac reflex (OCR; ≥20% HR reduction during extraocular muscle traction) triggered protocolized interventions, including fluid administration, dose adjustments, or rescue medications (ephedrine, atropine).

Outcome Measures

Primary Outcome: Extubation time (surgical dressing completion to LMA removal).
Secondary Outcomes: Surgical time, anesthetic time, OR exit time (surgery end to OR departure), Phase I (Aldrete score ≥9) and Phase II (PADSS score ≥9) recovery times. Complications (hypotension, bradycardia, OCR, PONV, pain) were recorded intraoperatively and post-discharge.

Results

Demographics: Groups were balanced in age (median ~26 years), sex (49% male in DES vs. 47% in TIVA), BMI, and surgical complexity.

ACT and Recovery Metrics:

  1. Extubation Time: DES significantly reduced median extubation time (5.5 [3.9–7.0] min) vs. TIVA (9.7 [8.5–11.4] min; P<0.001). No DES patients experienced prolonged extubation (≥15 min), whereas 6% of TIVA cases did (P=0.029).
  2. OR Exit Time: DES accelerated OR departure (7.3 [5.5–8.7] min vs. 10.8 [9.3–12.3] min; P<0.001).
  3. Surgical and Anesthetic Durations: Comparable between groups (P=0.313 and P=0.651, respectively).
  4. Recovery Phases: Phase I (~25 min) and Phase II (~58 min) times were similar (P=0.831 and P=0.573).

Hemodynamic Stability:

  • Hypotension: 1% (DES) vs. 22% (TIVA; P<0.001).
  • Bradycardia: 2% (DES) vs. 13% (TIVA; P=0.002).
  • OCR Incidence: 17% (DES) vs. 44% (TIVA; P<0.001).

Post-Operative Complications:

  • In-Hospital: DES had 3% cough incidence vs. 0% in TIVA (P=0.246). PONV (1% vs. 0%) and moderate-severe pain (4% vs. 3%) were comparable (P>0.05).
  • Post-Discharge: PDNV (6% DES vs. 2% TIVA), pain (14% both groups), and dizziness (15% vs. 12%) showed no significant differences (P>0.05). No unplanned hospitalizations occurred.

Discussion

ACT Efficiency: DES’s rapid pharmacokinetics, attributable to its low blood-gas partition coefficient (0.42), enabled faster emergence and OR turnover. Propofol’s context-sensitive half-time prolongation with prolonged infusion likely contributed to TIVA’s delayed extubation. Each 4.2-minute reduction in extubation time and 3.5-minute OR exit time advantage with DES translates to tangible OR efficiency gains, particularly in high-volume settings.

Hemodynamic Advantages: DES’s vagolytic properties mitigated OCR and sympathetic suppression from propofol-remifentanil synergy. TIVA’s higher hypotension and bradycardia rates may relate to propofol’s vasodilatory and negative inotropic effects, compounded by remifentanil’s vagotonic action.

Clinical Implications:

  • OR Throughput: Shorter ACT enhances scheduling flexibility, reducing labor costs and improving case turnover.
  • Stability in Ocular Surgery: DES’s hemodynamic profile benefits procedures sensitive to OCR, such as strabismus correction.
  • Limitations: Exclusion of higher-risk patients (ASA III–IV, obesity) limits generalizability. Unblinded anesthesia providers introduce potential bias, though standardized protocols mitigated variability.

Safety Considerations: DES’s 3% extubation cough rate underscores the need for smooth emergence strategies, such as deep extubation or adjunctive opioids, to avoid intraocular pressure spikes. Conversely, TIVA’s delayed recovery, though statistically significant, did not increase post-discharge complications.

Conclusion

In ambulatory strabismus surgery, desflurane anesthesia outperformed propofol-based TIVA in reducing ACT components (extubation and OR exit times) while providing superior hemodynamic stability. These advantages position DES as a preferred choice for enhancing OR efficiency in high-throughput ophthalmic settings. Future studies should explore DES’s applicability in broader patient populations and complex ocular procedures.

doi.org/10.1097/CM9.0000000000000728

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