Letters
COMMENT & RESPONSE PPCs would occur more frequently for several days in surgi-
Total Intravenous Anesthesia and Postoperative
Pulmonary Complications
To the Editor The randomized clinical trial by Chang et al1 con-
cluded that patients undergoing free flap surgery who received
total intravenous anesthesia (TIVA) had a lower incidence of post-
operative pulmonary complications (PPCs) than patients who re-
ceived inhalational anesthesia (INH). We read this article with
great interest but found some points worthy of discussion.
First, in the Preoperative Management section, the pa-
tients’ baseline hemoglobin levels and SpO2 were not de-
clared. However, both preoperative anemia and low SpO2 were
shown to be significant independent risk factors for PPCs.2
Second, in the Intraoperative Protocol section, the pa-
tients’ needs to receive blood products were not compared.
Blood transfusion is another independent risk factor for PPCs.3
In addition, because patients in the TIVA group had higher
blood pressure and higher fentanyl requirement, the authors
did not disclose if any antihypertensive medication was used
in the TIVA group. Some calcium channel blockers have been
reported to exhibit protective effect on bronchoconstriction.4
The mechanical ventilation setting was described; how-
ever, FiO2 use and the application of recruitment maneuvers
(RM) before initiating PEEP (positive end-expiratory pres-
sure) were not mentioned in the article. Previous studies have
demonstrated that atelectasis would develop in 75% of pa-
tients receiving GA involving neuromuscular blocking drugs
(NMBDs), especially when high FiO2 was used intraoperatively.2
When PEEP with RM were performed in combination, lung in-
fection, atelectasis, and acute lung injury were reduced.2
Finally, the primary outcome of this study was the inci-
dence of PPCs, but the timing when the adverse event was di-
agnosed was not discussed. The study protocol included 1 chest
radiographic scan when the patients arrived at the intensive
care unit (ICU), but no sonographic or computed tomo-
graphic scans were used to identify detailed pulmonary com-
plications during the following days after surgery.
We were surprised that the lower PPC rate in the TIVA group
did not shorten the length of hospitalization and ICU stay. This
possibly implies these PPCs detected were mild and not caus-
ing respiratory failure. However, no postoperative PaO2/FiO2
data were shown in this article.1 Studies have shown2,5 that
jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery Published online February 9, 2023
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cal patients receiving NMBDs, and mortality is increased in both
the short and long term in patients who develop a PPC.
We acknowledge the authors’ efforts to remind us of the
effects of anesthetic techniques on PPCs. But in this study,1 the
patients’ preoperative conditions and intraoperative manage-
ment should be described more thoroughly. The primary out-
come measurement, ie, the diagnosis of any PPC, remains an
issue to be further clarified.
Suet-Li Leong, MD
Shih-Hsuan Chen, MD, MS
James Cheng-Chung Wei, MD, PhD
Author Affiliations: Department of Anesthesiology, Chung Shan Medical
University Hospital, Taichung, Taiwan (Leong, Chen); Institute of Medicine,
Chung Shan Medical University, Taichung, Taiwan (Wei); Department of Allergy,
Immunology & Rheumatology, Chung Shan Medical University Hospital,
Taichung, Taiwan (Wei); Graduate Institute of Integrated Medicine, China
Medical University, Taichung, Taiwan (Wei).
Corresponding Author: James Cheng-Chung Wei, MD, PhD, Chung Shan
Medical University Hospital, No. 110 Jianguo N Rd, Section 1, South District,
Taichung City 40201, Taiwan (jccwei@gmail.com).
Published Online: February 9, 2023. doi:10.1001/jamaoto.2022.4964
Conflict of Interest Disclosures: None reported.
1. Chang YT, Lai CS, Lu CT, Wu CY, Shen CH. Effect of total intravenous
anesthesia on postoperative pulmonary complications in patients undergoing
microvascular reconstruction for head and neck cancer: a randomized clinical
trial. JAMA Otolaryngol Head Neck Surg. 2022;148(11):1013-1021. doi:10.1001/
jamaoto.2022.2552
2. Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth.
2017;118(3):317-334. doi:10.1093/bja/aex002
3. Clifford L, Jia Q, Subramanian A, et al. Characterizing the epidemiology of
postoperative transfusion-related acute lung injury. Anesthesiology. 2015;122(1):
12-20. doi:10.1097/ALN.0000000000000514
4. Kim YY, Holgate ST, Church MK. Inhibition of histamine release from
dispersed human lung and tonsillar mast cells by nicardipine and nifedipine. Br J
Clin Pharmacol. 1985;19(5):631-638. doi:10.1111/j.1365-2125.1985.tb02690.x
5. Jammer I, Wickboldt N, Sander M, et al; European Society of
Anaesthesiology (ESA) and the European Society of Intensive Care Medicine
(ESICM); European Society of Anaesthesiology; European Society of Intensive
Care Medicine. Standards for definitions and use of outcome measures for
clinical effectiveness research in perioperative medicine: European
Perioperative Clinical Outcome (EPCO) definitions: a statement from the
ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol.
2015;32(2):88-105. doi:10.1097/EJA.0000000000000118
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