Published online Nov 6, 2023. doi: 10.12998/wjcc.v11.i31.7619
Peer-review started: September 19, 2023
First decision: October 8, 2023
Revised: October 10, 2023
Accepted: October 23, 2023
Article in press: October 23, 2023
Published online: November 6, 2023
Processing time: 48 Days and 0.9 Hours
Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder that affects the elderly population and increases the risk of postoperative pulmo
To evaluate the protective effect of sevoflurane on the lung function of elderly COPD patients undergoing total hip arthroplasty (THA).
In this randomized controlled trial, we randomly assigned 120 elderly patients with COPD, who were scheduled for THA, to receive either sevoflurane (sevo
The results showed that the incidence of PPCs was significantly lower in the sevoflurane group than in the pro
Sevoflurane protects the lung function of elderly COPD patients undergoing THA under general anesthesia by reducing the incidence of PPCs, attenuating inflammatory and oxidative stress responses, and alleviating post
Core Tip: Sevoflurane exhibits a protective effect on lung function in elderly chronic obstructive pulmonary disease patients undergoing total hip arthroplasty. It reduces the incidence of postoperative pulmonary complications, improves lung function parameters, and decreases inflammatory and oxidative stress markers. Additionally, it alleviates postoperative pain. These findings highlight the potential benefits of using sevoflurane as an anesthesia choice for this patient population.
- Citation: Yao Y, Zhang MS, Li YB, Zhang MZ. Protective effect of sevoflurane on lung function of elderly chronic obstructive pulmonary disease patients undergoing total hip arthroplasty. World J Clin Cases 2023; 11(31): 7619-7628
- URL: https://www.wjgnet.com/2307-8960/full/v11/i31/7619.htm
- DOI: https://dx.doi.org/10.12998/wjcc.v11.i31.7619
Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease characterized by progressive air
COPD patients are at an increased risk of developing postoperative pulmonary complications (PPCs) after major sur
Total hip arthroplasty (THA) is a common orthopedic procedure performed to treat end-stage hip osteoarthritis or fractures[6]. THA can improve the quality of life and function of patients with hip disorders. However, it also involves significant surgical trauma and blood loss, which may impair lung function and increase the risk of PPCs[7]. THA is often performed under general anesthesia because it provides adequate muscle relaxation, analgesia, and amnesia[8]. However, general anesthesia may also have adverse effects on the lung function, including decreased lung volume, impaired gas exchange, increased airway resistance, and reduced mucociliary clearance[9].
Sevoflurane is a volatile anesthetic widely used for inducing general anesthesia for various surgical procedures[10]. Sevoflurane has several advantages over other anesthetics, such as rapid induction and emergence, minimal metabolism and toxicity, stable hemodynamics, and potent analgesia[11]. Moreover, sevoflurane has been shown to have anti-inflammatory and antioxidant properties and attenuate lung injury in animal models[12]. Several clinical studies have sugge
This study aimed to evaluate the protective effects of sevoflurane on the lung function of elderly patients with COPD undergoing THA under general anesthesia. We hypothesized that sevoflurane reduces the incidence of PPCs, attenuates the inflammatory and oxidative stress responses, and alleviates postoperative pain in these patients.
This prospective randomized controlled trial was conducted at our hospital between February 2018 and February 2023. The study protocol was approved by the Institutional Ethics Committee and registered in the Chinese Clinical Trial Registry (ChiCTR1900021234). Written informed consent was obtained from all the patients or their legal representatives.
We enrolled 120 elderly patients with COPD who were scheduled to undergo elective THA under general anesthesia. The inclusion criteria were as follows: (1) Age ≥ 65 years; (2) COPD diagnosis according to the Global Initiative for Chro
The exclusion criteria were as follows: (1) History of allergy or intolerance to sevoflurane or propofol; (2) History of liver or kidney dysfunction; (3) History of asthma, bronchiectasis, pulmonary fibrosis, or other lung diseases; (4) History of cardiac failure, arrhythmia, or ischemic heart disease; (5) History of diabetes mellitus, thyroid dysfunction, or immuno
Using a computer-generated random number table, the patients were randomly assigned to receive either sevoflurane (sevoflurane group) or propofol (propofol group) as the maintenance anesthetic. The allocation was concealed in sealed envelopes, which were opened by an independent anesthesiologist not involved in data collection or analysis. The patients, surgeons, and outcome assessors were blinded to the group allotment. Although the anesthesiologists administering the anesthetics were not blinded, they were instructed to follow a standardized protocol and avoid any interaction with the other staff members or patients. The statistical method of this study was reviewed by Rong Liu from Jiaxing Seco
Standardized preoperative preparations were performed for all patients, including fasting for 8 h before surgery, oral administration of 150 mg ranitidine and 5 mg diazepam on the night before surgery and on the morning of surgery, and intravenous administration of 2 g cefazolin 30 min before surgery. Premedication with intravenous midazolam (0.03 mg/kg) and fentanyl (1 μg/kg) was administered to all patients 10 min before anesthesia induction.
Anesthesia was induced by intravenous administration of 1.5-2 mg/kg propofol and 0.6 mg/kg rocuronium. After tracheal intubation, mechanical ventilation was initiated with a tidal volume of 6-8 mL/kg; respiratory rate, 12-14 breaths/min; inspiratory-to-expiratory ratio, 1:2; positive end-expiratory pressure, 5 cm H2O; and fraction of inspired oxygen, 0.5. Anesthesia was maintained with either sevoflurane or propofol according to the allotted group. The sevo
All patients underwent THA via the posterior approach performed by experienced orthopedic surgeons. A cemented femoral stem and an uncemented acetabular cup were implanted in all cases. The surgical duration, blood loss, trans
All patients received standardized postoperative management that included administration of intravenous fluids, antibiotics, analgesics, antiemetics, and anticoagulants and physiotherapy. The analgesic regimen comprised intravenous patient-controlled analgesia with morphine for 48 h, followed by oral acetaminophen and tramadol, as needed. The patients were encouraged to mobilize and perform breathing exercises as soon as possible after the surgery.
The primary outcome of this study was the incidence of PPCs within seven days after surgery. PPCs were determined when patients had pneumonia, atelectasis, respiratory failure, bronchospasm, or pleural effusion[17]. PPCs were diag
The secondary outcomes were the changes in the lung function parameters, inflammatory markers, oxidative stress markers, and postoperative pain scores. Lung function parameters included for
The inflammatory markers included interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Oxidative stress markers included malondialdehyde (MDA) and 8-hydroxy-2’-deoxyguanosine (8-OHdG). These markers were measured from the blood samples collected preoperatively and 24 h postoperatively using ELISA kits (R&D Systems, United States).
Postoperative pain scores were assessed using a visual analog scale, ranging from 0 (no pain) to 10 (worst imaginable pain). The pain scores were recorded at rest and during movement at 6 h, 12 h, and 24 h after surgery. Other outcomes included the length of hospital stay, morbidity, mortality, recurrence, and survival. Morbidity was defined as any adverse event that occurred within 30 d after surgery and required medical intervention. Mortality was defined as death due to any cause within 30 d after surgery. Recurrence was defined as radiological or histological evidence of tumor recurrence after surgery. Survival was defined as the time from surgery to death due to any cause or to the last follow-up.
Data were analyzed using Statistical Product and Service Solutions 22.0 software (IBM Corp., United States). Continuous variables are expressed as means ± SD or medians (interquartile ranges), depending on their distribution. Categorical variables are expressed as frequencies (percentages). The Kolmogorov-Smirnov test was used to determine the normality of data distribution. The inter-group differences were compared using the t-test or Mann-Whitney U test for continuous variables and the χ2 test or Fisher exact test for categorical variables. The changes in the lung function parameters, inflammatory markers, oxidative stress markers, and pain scores over time within each group were compared using repeated-measures analysis of variance or the Friedman test. The correlation between bile leakage and other outcomes was assessed using the Pearson correlation coefficient or Spearman rank correlation coefficient. Recurrence-free survival and overall survival were estimated using the Kaplan-Meier method and compared using the log-rank test. A multivariate logistic regression model was used to identify the independent risk factors for PPCs. P values < 0.05 were considered statistically significant.
This study included 120 elderly patients with COPD, who underwent THA under general anesthesia. These patients were randomly assigned to receive sevoflurane (sevoflurane group; n = 60) or propofol (propofol group; n = 60) as the main
Variables | Sevoflurane group | Propofol group | P value |
Age (yr) | 70.3 ± 4.2 | 69.8 ± 3.9 | 0.54 |
Sex (male/female) | 28/32 | 26/34 | 0.72 |
BMI (kg/m2) | 24.5 ± 2.8 | 25.1 ± 3.1 | 0.31 |
ASA class (I/II/III) | 0/36/24 | 0/38/22 | 0.81 |
COPD stage (II/III/IV) | 24/28/8 | 22/30/8 | 0.83 |
Smoking history (pack-years) | 18.6 ± 6.4 | 19.2 ± 7.1 | 0.62 |
Preoperative FEV1 (% predicted) | 58.7 ± 12.3 | 59.4 ± 11.9 | 0.74 |
Preoperative FVC (% predicted) | 65.2 ± 13.6 | 66.1 ± 12.8 | 0.67 |
Preoperative PEF (% predicted) | 54.3 ± 10.9 | 55.2 ± 11.2 | 0.59 |
Primary site of BTC (ICC/ECC/GBC) | 32/16/12 | 34/14/12 | 0.86 |
Tumor stage (I/II/III/IV) | 12/24/20/4 | 14/22/18/6 | 0.79 |
Type of hepatectomy (minor/major) | 36/24 | 38/22 | 0.81 |
Bile duct resection (yes/no) | 20/40 | 18/42 | 0.72 |
Surgical duration (min) | 165 ± 35 | 170 ± 40 | 0.42 |
Intraoperative blood loss (mL) | 420 ± 180 | 430 ± 190 | 0.68 |
Intraoperative transfusion (yes/no) | 16/44 | 14/46 | 0.74 |
Table 2 shows the postoperative outcomes of the two groups. The overall incidence of PPCs was 16.7%, and the median time to diagnosis was five days. The incidence of PPCs was significantly lower in the sevoflurane group than in the propofol group (10% vs 25%, P = 0.02). Atelectasis was the most common type of PPC, followed by pneumonia, respi
Variables | Sevoflurane group | Propofol group | P value |
PPCs (yes/no) | 6/54 | 15/45 | 0.02 |
Type of PPCs (n) | |||
Pneumonia | 2 | 4 | 0.67 |
Atelectasis | 3 | 9 | 0.14 |
Respiratory failure | 1 | 2 | 1.00 |
Bronchospasm | 0 | 1 | 1.00 |
Pleural effusion | 0 | 1 | 1.00 |
Severity of PPCs (n) | |||
Grade I | 3 | 7 | 0.32 |
Grade II | 2 | 7 | 0.14 |
Grade III | 1 | 1 | > 0.991 |
FEV1 (% predicted) | |||
Preoperatively | 58.7 ± 12.3 | 58.4 ± 11.9 | 0.74 |
24 h postoperatively | 52.3 ± 11.7 | 48.2 ± 10.8 | 0.03 |
48 h postoperatively | 54.6 ± 12.1 | 50.1 ± 11.2 | 0.02 |
FVC (% predicted) | |||
Preoperatively | 65.2 ± 13.6 | 66.1 ± 12.8 | 0.67 |
24 h postoperatively | 59.4 ± 13.2 | 54.8 ± 12.4 | 0.01 |
48 h postoperatively | 61.7 ± 13.5 | 56.3 ± 12.7 | 0.01 |
PEF (% predicted) | |||
Preoperatively | 54.3 ± 10.9 | 55.2 ± 11.2 | 0.59 |
24 h postoperatively | 49.5 ± 10.7 | 45.6 ± 10.3 | 0.02 |
48 h postoperatively | 51.8 ± 11.1 | 47.4 ± 10.6 | 0.01 |
IL-6 (pg/mL) | |||
Preoperatively | 15.4 ± 4.2 | 15.6 ± 4.5 | 0.81 |
24 h postoperatively | 25.2 ± 6.3 | 30.8 ± 7.1 | < 0.01 |
TNF-α (pg/mL) | |||
Preoperatively | 8.6 ± 2.1 | 8.7 ± 2.3 | 0.88 |
24 h postoperatively | 12.4 ± 3.2 | 15.6 ± 3.7 | < 0.01 |
MDA (nmol/mL) | |||
Preoperatively | 1.8 ± 0.5 | 1.9 ± 0.6 | 0.62 |
24 h postoperatively | 2.6 ± 0.7 | 3.2 ± 0.8 | < 0.01 |
8-OHdG (ng/mL) | |||
Preoperatively | 5.4 ± 1.2 | 5.6 ± 1.3 | 0.74 |
24 h postoperatively | 7.2 ± 1.6 | 8.8 ± 1.9 | < 0.01 |
VAS at rest (0-10) | |||
6 h postoperatively | 2.4 ± 1.1 | 3.2 ± 1.3 | < 0.01 |
12 h postoperatively | 2.1 ± 1.0 | 2.9 ± 1.2 | < 0.01 |
24 h postoperatively | 1.8 ± 0.9 | 2.6 ± 1.1 | < 0.01 |
VAS during movement (0-10) | |||
6 h postoperatively | 4.2 ± 1.4 | 5.4 ± 1.6 | < 0.01 |
12 h postoperatively | 3.8 ± 1.3 | 5.0 ± 1.5 | < 0.01 |
24 h postoperatively | 3.4 ± 1.2 | 4.6 ± 1.4 | < 0.01 |
Length of hospital stay (d) | 12 (10-14) | 18 (15-21) | < 0.011 |
Morbidity (yes/no) | 8/52 | 18/42 | < 0.011 |
Mortality (yes/no) | 2/58 | 3/57 | > 0.991 |
Recurrence-free survival (mo) | |||
Median | 18 | 19 | 0.38 |
95%CI | 15-21 | 16-22 | |
Overall survival (mo) | |||
Median | 24 | 25 | 0.46 |
95%CI | 21-27 | 22-28 |
This study demonstrated that sevoflurane exerts a protective effect on the lung function of elderly patients with COPD undergoing THA under general anesthesia by reducing the incidence of PPCs, attenuating inflammatory and oxidative stress responses, and alleviating postoperative pain.
The incidence of PPCs in our study was consistent with that reported in the literature[20]. PPCs are multifactorial events influenced by patient-, surgery-, and anesthesia-related factors[21]. COPD is a well-known risk factor for PPCs because it causes chronic inflammation, airway obstruction, mucus hypersecretion, and impaired gas exchange in the lungs[22]. These changes may predispose COPD patients to infection, atelectasis, respiratory failure, and other PPCs after surgery[23].
We found that compared with propofol, sevoflurane significantly reduced the incidence of PPCs in elderly patients with COPD, which corroborates previous findings[13-15]. The possible mechanisms of sevoflurane-induced lung pro
Sevoflurane may exert anti-inflammatory effects by inhibiting the activation of nuclear factor-kappa B and production of pro-inflammatory cytokines, such as IL-6 and TNF-α[24]. These cytokines may play key roles in the pathogenesis of PPCs by inducing lung inflammation, edema, and injury[25]. We found that sevoflurane significantly reduced the levels of IL-6 and TNF-α after surgery in elderly patients with COPD, indicating its anti-inflammatory properties.
Sevoflurane may exert antioxidant effects by scavenging reactive oxygen species (ROS) and enhancing the activity of antioxidant enzymes such as superoxide dismutase and catalase[26]. ROS may contribute to PPCs by causing oxidative stress, lipid peroxidation, DNA damage, and apoptosis in the lung cells[27]. We found that sevoflurane significantly redu
Sevoflurane may exert analgesic effects by modulating the activity of opioid receptors, gamma-aminobutyric acid receptors, and N-methyl-D-aspartate receptors[28]. Postoperative pain may aggravate PPCs by causing shallow breath
We also found that sevoflurane significantly attenuated the decline in the lung function parameters, such as FEV1, FVC, and PEF, in elderly patients with COPD after surgery. These parameters are important indicators of lung function and airflow limitation in COPD patients[30]. Reduced lung function after surgery may be caused by several factors, such as surgical trauma, blood loss, fluid overload, anesthesia-induced muscle relaxation, mechanical ventilation-induced lung injury, and PPCs[31]. Sevoflurane may preserve lung function by reducing these factors through its anti-inflammatory, antioxidant, and analgesic effects.
We did not find any significant differences in the length of hospital stay, morbidity, mortality, recurrence, or survival between the two groups. This may be due to the following reasons: (1) The sample size of this study was relatively small and may not have enough power to detect the differences in these outcomes; (2) The PPCs in this study were mostly mild and did not require intensive care or invasive interventions; (3) The postoperative management and follow-up of the patients were standardized and optimized; and (4) The recurrence and survival of patients with biliary tract cancer may be more influenced by tumor-related factors than by anesthetic-related factors.
This study has some limitations. First, this was a single-center study with a relatively small sample size and a short follow-up period. Therefore, these results may not be generalizable to other settings or populations. Second, this study only compared sevoflurane with propofol as the maintenance anesthetic. Other anesthetic agents, such as desflurane or dexmedetomidine, may have different effects on the lung function and PPCs in elderly patients with COPD. Third, this study did not measure other lung function parameters, such as lung volume, capacity, or diffusion capacity. These parameters may provide comprehensive information regarding lung function and injury in COPD patients. Fourth, this study did not measure other inflammatory or oxidative stress markers, such as C-reactive protein, IL-8, nitric oxide, or glutathione. These markers may reflect different aspects of lung inflammation and oxidative stress. Fifth, this study did not evaluate the quality of recovery or patient satisfaction after surgery. These outcomes may also be affected by the choice of the anesthetic agent.
This study showed that sevoflurane exerts a protective effect on the lung function of elderly patients with COPD undergoing THA under general anesthesia by reducing the incidence of PPCs, attenuating inflammatory and oxidative stress responses, and alleviating postoperative pain. Sevoflurane may be the preferred anesthetic agent in such patients who require THA. Further studies with larger sample sizes and longer follow-up periods are warranted to confirm these findings and explore the underlying mechanisms.
Chronic obstructive pulmonary disease (COPD) is a prevalent and progressive respiratory disorder that primarily affects the elderly population. COPD is associated with significant morbidity and mortality and poses challenges in the perioperative management of elderly patients undergoing major surgeries. Postoperative pulmonary complications (PPCs) are a frequent and serious concern in this patient population, leading to increased healthcare utilization, prolonged hospital stays, and compromised patient outcomes.
The study aimed to compare the incidence of PPCs and changes in lung function parameters, inflammatory and oxidative stress markers, and postoperative pain scores in elderly COPD patients receiving either sevoflurane or propofol as the maintenance anesthetic during total hip arthroplasty (THA).
The main objective of this study was to evaluate the protective effect of sevoflurane on the lung function of elderly COPD patients undergoing THA.
This study utilized a randomized controlled trial design to assess the protective effect of sevoflurane on the lung function of elderly COPD patients undergoing THA. Random assignment of 120 patients to either the sevoflurane or propofol group minimized bias. During surgery, patients in the sevoflurane group received sevoflurane as the maintenance anesthetic, while those in the propofol group received propofol. The primary outcome was the incidence of PPCs within seven days, and secondary outcomes included changes in lung function parameters, inflammatory and oxidative stress markers, and postoperative pain scores. The study concluded that sevoflurane administration significantly reduced PPCs, mitigated inflammation and oxidative stress responses, and improved postoperative pain. The novelty of this research lies in its focus on elderly COPD patients undergoing THA and the comparison of sevoflurane and propofol in this popu
The study findings revealed that sevoflurane administration during THA under general anesthesia significantly reduced the incidence of PPCs in elderly COPD patients compared to propofol. The sevoflurane group also exhibited a lesser decline in lung function parameters, which included forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF), at 24 h and 48 h after surgery. Furthermore, sevoflurane administration was associated with significantly lower levels of inflammatory and oxidative stress markers, such as interleukin-6, tumor necrosis factor-alpha, malondialdehyde, and 8-hydroxy-2 α-deoxyguanosine, at 24 h after surgery. The sevoflurane group also exhibited significantly lower postoperative pain scores at 6 h, 12 h, and 24 h after surgery. Therefore, the study concluded that sevoflurane administration provides protective effects on lung function, attenuates inflammatory and oxidative stress responses, and alleviates postoperative pain in elderly COPD patients undergoing THA. Additionally, the study did not evaluate long-term outcomes or the potential impact of sevoflurane on mortality or quality of life. Future studies should address these limitations to further advance knowledge in the field of perioperative care for elderly COPD patients.
This study provides evidence that sevoflurane administration during THA in elderly COPD patients under general anesthesia significantly reduces the incidence of PPCs, mitigates inflammatory and oxidative stress responses, and alleviates postoperative pain. Sevoflurane also exhibits a protective effect on lung function, as demonstrated by a lesser decline in lung function parameters, including FEV1, FVC, and PEF, at 24 h and 48 h after surgery. These findings sup
The findings of this study provide valuable insights into the potential benefits of sevoflurane in protecting the lung function of elderly COPD patients undergoing major surgeries, specifically THA. Future research can build upon these findings in several ways. First, additional studies should explore the generalizability of these results to other surgical procedures and patient populations. This would enhance our understanding of the broader applicability of sevoflurane’s protective effects. Second, long-term outcomes, such as mortality rates and quality of life measures, should be investigated to assess the sustained impact of sevoflurane on patient outcomes. Furthermore, further investigations are warranted to elucidate the underlying mechanisms through which sevoflurane exerts its protective effects, including its anti-inflammatory and antioxidant properties. Overall, these research perspectives can enhance the knowledge and cli
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