Anesthesia Management in Surgical Procedures

Introduction to Anesthesia Techniques

The American Society of Anesthesiologists recommends choosing one predominant anesthesia technique (TIVA with propofol or inhalation anesthesia with halogenated gases) based on the specific needs of the patient and the procedure, rather than routinely combining both techniques 1, 2

In cardiac surgery with cardiopulmonary bypass, propofol can be co-administered with volatile anesthetics, as documented in studies where patients received propofol along with halogenated gases during cardiac procedures 3
The combination of propofol and halogenated gases may occur during transitions in cardiac surgery, particularly when initiating or terminating cardiopulmonary bypass, although this represents more of a transition between techniques than a true intentional combination 3
The British Journal of Anaesthesia suggests that the requirements for volatile anesthetics are temperature-dependent, with lower requirements during systemic hypothermia and higher requirements during rewarming, which may lead to supplementation with propofol 3

The use of propofol alone can result in a significant reduction in postoperative nausea and vomiting compared to volatile anesthetics, especially important in major abdominal surgery 2
Propofol does not irritate the respiratory tract, which is particularly important during tracheal surgery or when the airway is directly manipulated 4
Halogenated gases, such as isoflurane and sevoflurano, provide cardioprotection in the context of ischemia and reperfusion, leading to their widespread use in coronary revascularization surgery 2

The American Society of Anesthesiologists recommends maintaining a BIS (bispectral index) between 40-60 to prevent intraoperative consciousness and avoid excessive depth when using any anesthesia technique 5
Both propofol and halogenated gases can cause hypotension due to vasodilation, which can have additive effects when combined, requiring continuous monitoring of heart rate, blood pressure, and pulse oximetry 3, 5
Vasopressors, such as ephedrine or metaraminol, should be immediately available to treat hypotension, considering elevation of lower limbs or pressor agents when additional fluid therapy is contraindicated 5

The American Society of Anesthesiologists recommends transitioning from propofol TCI to sevoflurane inhalation during surgery by starting sevoflurane at 2-3% in oxygen/air while simultaneously reducing the propofol infusion by 50%, then discontinuing propofol completely once end-tidal sevoflurane reaches 1.5-2% (approximately 5-10 minutes), maintaining depth of anesthesia monitoring with BIS 40-60 throughout the transition 6, 7

The World Health Organization considers sevoflurane an essential medicine, and its use may be indicated in cases of equipment failure or malfunction of TCI pump requiring alternative anesthetic technique, or when institutional or regional availability considerations are a factor 6, 7
The decision to transition from propofol to sevoflurane should prioritize patient-specific factors, surgical requirements, and clinical judgment rather than routine practice, as there is no strong evidence recommending one maintenance technique over another for major postoperative outcomes including complications, mortality, or length of stay 6, 7, 8

The World Journal of Emergency Surgery notes that transitioning from propofol to sevoflurane may increase postoperative nausea and vomiting (PONV) risk, and considers administering multimodal PONV prophylaxis if transition occurs, particularly in high-risk patients 9

When administered without nitrous oxide at a fresh‑gas flow of 0.5 L/min using modern manufacturing processes, sevoflurane generates approximately 0.996 kg CO₂ per MAC‑hour, which is comparable to the 1.013 kg CO₂ per MAC‑hour produced by propofol TIVA. This data derives from recent life‑cycle assessments published in Anaesthesia (2024) 10, 11.

Existing lifecycle‑assessment literature is incomplete, as it does not fully evaluate non‑greenhouse‑gas impacts such as propofol water toxicity and plastic waste from infusion sets. Consequently, clinical decisions should prioritize patient‑centered outcomes rather than rely solely on the available environmental metrics 12, 13, 14.

The World Health Organization (WHO) lists sevoflurane as an essential medicine, whereas the equipment required for total‑intravenous anesthesia (TIVA) and depth‑of‑anesthesia monitoring may not be universally accessible, influencing feasibility in resource‑limited settings 12.

Professional guidance advises that patient needs and established best practices should remain the primary drivers of anesthetic choice; environmental impact alone should not dictate selection until more comprehensive lifecycle data become available 12, 13, 14.