This study compares the clinical profile of propofol anesthesia for direct laryngoscopy with spontaneous ventilation when the drug is administered either as a manually controlled infusion or by targeting the effect-site concentration through a target-controlled infusion (TCI) device. TCI improves the time course of propofol effects.

Entropy predicted a motor response to noxious stimulations but not a hemodynamic response, which limits its usefulness for assessing the analgesic component of anesthesia in paralyzed patients. High values (RE >55) before the stimulation should be avoided in order to decrease the risk of motor response, but lower values might not prevent this response when the opioid concentration is insufficient, despite an adequate hypnosis.

Elderly patients have a higher risk of developing adverse drug reactions during anesthesia, especially anesthesia affecting cardiovascular performance. In this prospective randomized study we compared quality of induction, hemodynamics, and recovery in elderly patients scheduled for hip fracture surgery and receiving either etomidate/desflurane (ETO/DES) or target-controlled (TCI) or manually controlled (MAN) propofol infusion for anesthesia. Sixteen patients were anesthetized with ETO (0.4 mg/kg) followed by DES titrated from an initial end-tidal concentration of 2.5%. Eighteen patients received propofol TCI at an initial plasma concentration of 1 microg/mL and titrated upwards by 0.5-microg/mL steps. Fifteen patients received a bolus induction of propofol 1 mg/kg over 60 s followed by an infusion initially set at 5 mg . kg(-1) . h(-1). All received a bolus (20 microg/kg) followed by an infusion of 0.4 microg . kg(-1) . min(-1) alfentanil. According to hemodynamics, concentrations of DES or propofol (TCI group) and propofol infusion rate (MAN group) were respectively adjusted by a step of 20% and 50%. In the TCI and ETO/DES groups, the time spent at a mean arterial blood pressure within 15% and 30% of baseline values was more than 60% and 80% of anesthesia time, whereas in the MAN group it was <30% and 60%, respectively. In the MAN group more anesthetic drug adjustments were recorded (6.4 +/- 2.8 versus 2.5 +/- 1.2 [ETO/DES] and 2.6 +/- 1 [TCI]). TCI improves the time course of propofol's hemodynamic effects in elderly patients.

In patients'≥75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints.

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IntroductionElderly patients constitute an increasingly large proportion of the high-risk surgical group. In adult patients, several specific intraoperative approaches such as cardiac output-guided haemodynamic therapy, depth of anaesthesia monitoring (DAM) or lung-protective ventilation (LPV) are designed to reduce postoperative mortality and surgical complications. However, none of these approaches has been specifically performed in the elderly, and no evaluation of a multimodal optimisation strategy for general anaesthesia has been achieved in this population.AimsThe objective of this study is to assess, in high-risk patients aged 75 years and over undergoing high-risk surgery, the effectiveness of combined optimisation of anaesthesia involving goal-directed haemodynamic therapy (GDHT), LPV and electroencephalographic DAM on postoperative morbidity and mortality. The primary outcome of the study is a composite criterion associating major postoperative complications and mortality occurring within the 30 first postoperative days. The secondary outcomes are 1-year postoperative autonomy and mortality.Methods and analysisThis prospective, randomised, controlled, multicentre trial using a stepped wedge cluster design will be conducted in 27 French university centres. Patients aged 75 years and over, undergoing femoral head fractures and major intraperitoneal or vascular elective surgeries will be included after informed consent. They will benefit from usual care in the ‘control group’ and from a combined optimisation of general anaesthesia involving GDHT, LPV and DAM in the ‘optimisation group’. The cluster’s crossover will be unidirectional, from control to optimisation, and randomised. Data will be recorded at inclusion, the day of surgery, 7 days, 30 days and 1year postoperatively and collected into a hosted electronic case report form. The primary outcome of the study is a composite criterion associating major postoperative complications and mortality occurring within the 30 first postoperative days. The secondary outcomes are 1- year postoperative autonomy and mortality.Ethics and disseminationThis protocol was approved by the ethics committee Sud-Est 1 and the French regulatory agency. The finding of the trial will be disseminated through peer-reviewed journals and conferencesTrial registration numberNCT02668250