Effects of Desflurane Versus Propofol on Hemostasis During Splenectomy

Perioperative Effect of Desflurane Versus Total Intravenous Anesthesia With Propofol on Hemostasis Guided by Thromboelastometry in Splenectomy With Liver Cirrhosis.

The aim of this prospective randomized study is to evaluate the perioperative effects of inhalational anesthesia (desflurane) and intravenous anesthesia (propofol) on hemostasis in patients undergoing splenectomy with liver cirrhosis guided by the new technology (ROTEM) and the traditional laboratory hemostatic markers.

Study Overview

• Status: Completed
• Conditions: Status; Splenectomy
• Intervention / Treatment: Drug: Desflurane; Drug: Propofol

Detailed Description

After obtaining approval from the Institutional Research Ethics Committee and informed written consent, thirty adult patients aged 25- 55 years of either sex, American Society of Anesthesiologists (ASA) class II- III (Child A) suffering from cytopenia scheduled for elective splenectomy will be recruited. Pancytopenia is defined as anemia (hemoglobin < 13.5 g/dL-male; <12 g/dL-female); leucopenia (total leukocyte count < 4,000/mm3) and thrombocytopenia (platelet count < 150,000/mm3). Child B and C, Hb < 10 g/dL platelet count < 50,000/mm3, White Blood Cells (WBCs) < 2,000/mm3, prothrombin time [PT] > 16 s and INR > 1.7, extremes of age, obese patients (body mass index >35 kg m-2), and those using oral anticoagulants, other antithrombotic drugs, or oral contraceptives, will be excluded from the study.

All patients will be premedicated with 0.05 mg kg-1 i.v midazolam half an hour before operation. In the operating room, continuous pulse oximetry, electrocardiogram, non-invasive arterial blood pressure, PECO2, end-tidal anesthetic agent, neuromuscular monitoring, core temperature (Infinity Kappa, Dräger, Lübeck, Germany) and hourly urine output will be monitored throughout the operation. Depth of anesthesia will be monitored by using Bispectral index (BIS). All IV fluids will be warmed, and a warm air blanket (Bair Hugger) will be applied to every patient.

Thirty eligible patients will be allocated randomly to one of two equal groups (15 patients each) according to a computer generated randomization list: group D; maintenance of anesthesia with inhaled desflurane at 1 minimum alveolar concentration (MAC); group P, maintenance of anesthesia with target-controlled infusion (TCI) propofol with a target plasma concentration of propofol between 2 and 5 µg ml-1. The concentration of volatile anesthetics or the rate of infusion of injected anesthetics will be titrated to maintain the BIS numerical value between 40-50.

Anesthesia will be induced in both groups using i.v. fentanyl 1.5- 2 µg kg-1 and propofol 2- 2.5 mg kg-1. Atracurium 0.5 mg kg-1 will be administered for neuromuscular block and continued according to the response to train-of-four peripheral nerve stimulation. After intubation, patients will be mechanically ventilated with 30% oxygen in air throughout surgery using a low flow system (1L min-1) to adjust an end-tidal carbon dioxide (PECO2) between 30- 35 mmHg. Acetated Ringer's solution will be given as a preload and maintenance at a rate of 5-7 ml kg-1 h-1. Patients' systolic arterial pressures will be maintained at 100 mmHg or 70% of the preoperative value, whichever is higher. Hypotension will be treated with i.v. crystalloid fluid loading or intravenous boluses of ephedrine as appropriate. No colloid transfusion will be allowed. Transfusions of red blood cells will be used to maintain hemoglobin levels equal to or above 8 g dl-1. Platelets or fresh frozen plasma will be infused only when indicated by ROTEM. At the end of surgery, neuromuscular blockade will be antagonized with 0.05 mg kg-1 neostigmine and 0.02 mg kg-1 atropine. Postoperative analgesia was provided by intravenous infusion of 1 gm acetaminophen and IV meperidine 1 mg kg-1 every 12 hours. Patients are given an anti-emetic ondansetron 4 mg postoperatively.

Blood Sampling:

Five blood samples will be collected; before operation, after ligation of splenic artery, immediate post-operative, 24 hours and three days after the operation. Each time, five ml of venous blood will be collected and assessment of the following parameters will be performed:

Complete blood picture:

1. Hemoglobin Concentration (by electronic cell counter).
2. Hematocrit (by electronic cell counter).
3. Platelet count (by electronic cell counter).
4. Red blood cells (by electronic cell counter).
5. White blood cells (by electronic cell counter).

Screening hemostatic tests:

1. Prothrombin Time (PT) (by conventional method).
2. International Normalized Ratio (INR) (by conventional method).
3. Partial Thromboplastin Time (PTT) (by conventional method).

Specific hemostatic tests:

1. Soluble platelet selectin (sP-selectin) [enzyme-linked immunosorbent assay (ELISA)].
2. Fibrinogen level (coagulation method).
3. D-dimer level (ELIZA).

At each sample time (0.3 ml blood) will be taken for measuring the following ROTEM variables:

• The time until initial fibrin formation (clotting time CT).
• The kinetics of fibrin formation and clot development (clot formation time (CFT) and α- angle).
• The ultimate strength and stability of the fibrin clot (maximum clot firmness MCF).
• Clot lysis (fibrinolysis). The previous parameters provide information about platelet activation, fibrin formation and clot retraction (all stages of the developing and resolving clot). Blood samples are activated extrinsically (by tissue factor) and intrinsically (by contact activator) via commercially available tests. Furthermore, fibrinogen levels will be assessed by measuring clot strength (MCF) in the presence of platelet inhibition (e.g., fib-TEM). This modified MCF represents the fibrin clot that developed in the absence of any platelets, i.e., the functional fibrinogen [6].

Routine laboratory tests:

1. Serum creatinine.
2. Alanine aminotransferase (ALT),aspartate aminotransferase (AST), albumin, bilirubin.

Routine investigations will be performed pre-, post-operative and on the third day.

Follow up of each patient will be done at out-patients clinic after one month to have thorough clinical examination, liver and kidney function tests, Child's Turcotte Pugh (CTP) score assessment, laboratory hematological tests and ROTEM assessment. This is important to assess post-operative complications, efficacy of splenectomy in improving cytopenia, and the influence of splenectomy on the natural course of disease.

Statistical Analysis:

No previous study was conducted to assess the effects of anesthetic agents on hemostasis during splenectomy with liver cirrhosis guided by ROTEM. Thus the calculation of the sample size is difficult and also the reagents required for ROTEM are expensive so we designed this thesis to be a pilot study. A sample size was chosen to be 15 patients in each group. Comparison between the two groups will be performed using Mann-Whitney test, while comparison within each group will be performed using Wilcoxon sign rank test. Comparison between repeated measures in both groups was performed using ANOVA. The data are considered significant if p values are ≤ 0.05. Statistical analysis will be performed with the aid of the Statistical Package for the Social Sciences (SPSS) computer program, version 12 windows (IBM, USA).

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• Study Type: Interventional
• Enrollment (Actual): 30
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Egypt
  • Giza, Egypt, 12411
    • Theodor Bilharz research institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 25 years to 55 years (ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patient ASA physical status II and III.
• Age between 22-55 years.
• Child A suffering from pancytopenia.
• Type of surgery: splenectomy

Exclusion Criteria:

• Patients using oral anticoagulants
• Patients using antithrombotic drugs
• Patients using non steroidal anti-inflammatory drugs
• Patients using oral contraceptives
• Age less than 25 or more than 55 years
• Obese patients (body mass index >35 kg m-2)
• Pregnancy and lactation

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: DOUBLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Desflurane; Desflurane at 1 MAC and	Drug: Desflurane; Inhalational anesthetic; Other Names: Suprane
EXPERIMENTAL: propofol; propofol TCI (target controlled infusion) infusion of to keep a target plasma concentration between 2 and 5 µg ml-1	Drug: Propofol; Intravenous anesthetic that can be given by continuous infusion; Other Names: Diprivan

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
maximum clot firmness (MCF)	Ultimate strength and stability of the fibrin clot measured by ROTEM.	Up to 1 month

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
clotting time CT	The time until initial fibrin formation measured by ROTEM	Up to 1 month
clot formation time; CFT	The kinetics of fibrin formation and clot development measured by ROTEM	Up to 1 month
D dimer	Indication of coagulation and fibrinolysis	Up to 1 month
Platelet count	Ability of clot formation	Up to 1 month
Prothrombin Time	measures of the extrinsic pathway of coagulation	Pre-operative, after ligation of splenic artery, immediate post-operative, 24 hours and three days after operation
International Normalized Ratio (INR)	measures of the extrinsic pathway of coagulation	Pre-operative, after ligation of splenic artery, immediate post-operative, 24 hours and three days after operation
sP-selectin	Acts as a receptor that supports binding of leukocytes to activated platelets and endothelium.	Pre-operative, after ligation of splenic artery, immediate post-operative, 24 hours and three days after operation
Fibrinogen Level	A soluble plasma glycoprotein, that is converted by thrombin into fibrin during blood clot formation	Pre-operative, after ligation of splenic artery, immediate post-operative, 24 hours and three days after operation
D-Dimer	A fibrin degradation product (or FDP) present in the blood after a blood clot is degraded by fibrinolysis	Pre-operative, after ligation of splenic artery, immediate post-operative, 24 hours and three days after operation

Collaborators and Investigators

• Sponsor: Theodor Bilharz Research Institute
• Investigators: Study Chair: Gehan G El-Fandy, M.D., Theodor Bilharz research institute

Publications and helpful links

General Publications

• Senzolo M, Burra P, Cholongitas E, Burroughs AK. New insights into the coagulopathy of liver disease and liver transplantation. World J Gastroenterol. 2006 Dec 28;12(48):7725-36. doi: 10.3748/wjg.v12.i48.7725.
• Liangpunsakul S, Ulmer BJ, Chalasani N. Predictors and implications of severe hypersplenism in patients with cirrhosis. Am J Med Sci. 2003 Sep;326(3):111-6. doi: 10.1097/00000441-200309000-00001.

Helpful Links

• Senzolo M, Burra P, Cholongitas E, Burroughs AK. New insights into the coagulopathy of liver disease and liver transplantation. World J Gastroenterol 2006; 12(48): 7725-36
• Liangpunsakul S, Sithat M, Ulmer B, Chalasani. Predictors and implications of severe hypersplenism in patients with cirrhosis. Am J Med Sciences 2003; 326: 111-16.

Study record dates

Study Major Dates

• Study Start: January 1, 2014
• Primary Completion (ACTUAL): June 1, 2017
• Study Completion (ACTUAL): July 1, 2017

Study Registration Dates

• First Submitted: February 27, 2014
• First Submitted That Met QC Criteria: March 4, 2014
• First Posted (ESTIMATE): March 5, 2014

Study Record Updates

• Last Update Posted (ACTUAL): October 11, 2017
• Last Update Submitted That Met QC Criteria: October 10, 2017
• Last Verified: October 1, 2016

More Information

Terms related to this study

• Keywords: Propofol; Desflurane; ROTEM; TCI; Splenectomy
• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Central Nervous System Depressants; Anesthetics, Intravenous; Anesthetics, General; Anesthetics; Hypnotics and Sedatives; Anesthetics, Inhalation; Propofol; Desflurane
• Other Study ID Numbers: Anesthesia 98T

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO