Correspondence  |   February 2012
Propofol and Additives: Please Consider Zebras Besides Horses When You Hear Hooves
Author Affiliations & Notes
  • Saban Yalcin, M.D.
  • *Harran University Medical Faculty, Şanlıurfa, Turkey.
Article Information
Correspondence   |   February 2012
Propofol and Additives: Please Consider Zebras Besides Horses When You Hear Hooves
Anesthesiology 2 2012, Vol.116, 492. doi:
Anesthesiology 2 2012, Vol.116, 492. doi:
To the Editor: 
We read with great interest the article by Schilling et al.  dealing with effects of sevoflurane and desflurane as volatile anesthetics compared with propofol as an intravenous anesthetic and the relationship between pulmonary and systemic inflammation in patients undergoing open thoracic surgery.1 Authors remarked that proinflammatory cytokines increased in the ventilated lung after one lung ventilation. Mediator release was more enhanced during propofol anesthesia compared with desflurane or sevoflurane administration. Postoperatively, the proinflammatory cytokines tumor necrosis factor- α (P  < 0.001), interleukin-1β (IL-1β) (P  < 0.002), and interleukin 8 (IL-8) (P  < 0.025) were more increased in patients during propofol administration compared with both volatile anesthesia groups, and postoperative serum concentration of IL-6 was increased in all patient groups after thoracic surgery (P  < 0.001). The authors concluded that one-lung ventilation increases the alveolar concentrations of proinflammatory mediators in the ventilated lung. Both desflurane and sevoflurane suppress the local alveolar, but not the systemic, inflammatory responses to one-lung ventilation and thoracic surgery.
Lung injury after thoracic surgery is a relatively uncommon but major complication with high mortality. Many factors, including cytokine imbalance, ischemia reperfusion injury, and the use of one-lung ventilation, are involved in this process apart from the surgical insult itself.2 In our opinion, a point of this work is not sufficiently clear. EDTA and sulfite might be added as antimicrobial agents to several formulations of propofol, which may have different physiologic responses. Herr et al.  3 showed that the patients in the surgical intensive care unit receiving propofol with EDTA had significantly reduced mortality rates at 7 and 28 days compared with those receiving propofol without EDTA. Haitsma et al.  4 compared the effects of propofol with EDTA, propofol with sulfite, and ketamine/midazolam on tumor necrosis factor- α, interleukin-6 (IL-6), and macrophage inflammatory protein-2 in an animal study. They showed that bronchoalveolar lavage IL-6 was significantly higher in the propofol with sulfite group compared with both the ketamine/midazolam and the propofol with EDTA groups. They also remarked that pulmonary IL-6 can be modulated by additives in systemic anesthesia.
Accordingly, we think that reporting detailed formula of propofol in studies evaluating the effect of propofol on inflammatory responses would be crucial, and we hope that the previously mentioned comments might add to the value of the manuscript by Schilling et al.  1 
Schilling T, Kozian A, Senturk M, Huth C, Reinhold A, Hedenstierna G, Hachenberg T: Effects of volatile and intravenous anesthesia on the alveolar and systemic inflammatory response in thoracic surgical patients. ANESTHESIOLOGY 2011; 115:65–74
Gothard J: Lung injury after thoracic surgery and one-lung ventilation. Curr Opin Anaesthesiol 2006; 19:5–10
Herr DL, Kelly K, Hall JB, Ulatowski J, Fulda GJ, Cason B, Hickey R, Nejman AM, Zaloga GP, Teres D: Safety and efficacy of propofol with EDTA when used for sedation of surgical intensive care unit patients. Intensive Care Med 2000; 26:S452–62
Haitsma JJ, Lachmann B, Papadakos PJ: Additives in intravenous anesthesia modulate pulmonary inflammation in a model of LPS-induced respiratory distress. Acta Anaesthesiol Scand 2009; 53:176–82