Kampman Jasper M, Hermanides Jeroen, Hollmann Markus W, Gilhuis Coenraad N, Bloem Wouter Ah, Schraag Stefan, Pradelli Lorenzo, Repping Sjoerd, Sperna Weiland Nicolaas H
Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
Amsterdam UMC Centre for Sustainable Healthcare, Amsterdam UMC, Amsterdam, the Netherlands.
EClinicalMedicine. 2024 May 14;72:102636. doi: 10.1016/j.eclinm.2024.102636. eCollection 2024 Jun.
General anaesthesia is provided to more than 300 million surgical patients worldwide, every year. It is administered either through total intravenous anaesthesia, using only intravenous agents, or through inhalational anaesthesia, using volatile anaesthetic agents. The debate on how this affects postoperative patient outcome is ongoing, despite an abundance of published trials. The relevance of this topic has grown by the increasing concern about the contribution of anaesthetic gases to the environmental impact of surgery. We aimed to summarise all available evidence on relevant patient outcomes with total intravenous anaesthesia versus inhalational anaesthesia.
In this systematic review and meta-analysis, we searched PubMed/Medline, Embase and Cochrane Central Register of Controlled trials for works published from January 1, 1985 to August 1, 2023 for randomised controlled trials comparing total intravenous anaesthesia using propofol versus inhalational anaesthesia using the volatile anaesthetics sevoflurane, desflurane or isoflurane. Two reviewers independently screened titles, abstracts and full text articles, and assessed risk of bias using the Cochrane Collaboration tool. Outcomes were derived from a recent series of publications on consensus definitions for Standardised Endpoints for Perioperative trials (StEP). Primary outcomes covered mortality and organ-related morbidity. Secondary outcomes were related to anaesthetic and surgical morbidity. This study is registered with PROSPERO (CRD42023430492).
We included 317 randomised controlled trials, comprising 51,107 patients. No difference between total intravenous and inhalational anaesthesia was seen in the primary outcomes of in-hospital mortality (RR 1.05, 95% CI 0.67-1.66, 27 trials, 3846 patients), 30-day mortality (RR 0.97, 95% CI 0.70-1.36, 23 trials, 9667 patients) and one-year mortality (RR 1.14, 95% CI 0.88-1.48, 13 trials, 9317 patients). Organ-related morbidity was similar between groups except for the subgroup of elderly patients, in which total intravenous anaesthesia was associated with a lower incidence of postoperative cognitive dysfunction (RR 0.62, 95% CI 0.40-0.97, 11 trials, 3834 patients) and a better score on postoperative cognitive dysfunction tests (standardised mean difference 1.68, 95% CI 0.47-2.88, 9 trials, 4917 patients). In the secondary outcomes, total intravenous anaesthesia resulted in a lower incidence of postoperative nausea and vomiting (RR 0.61, 95% CI 0.56-0.67, 145 trials, 23,172 patients), less emergence delirium (RR 0.40, 95% CI 0.29-0.56, 32 trials, 4203 patients) and a higher quality of recovery score (QoR-40 mean difference 6.45, 95% CI 3.64-9.25, 17 trials, 1835 patients).
The results indicate that postoperative mortality and organ-related morbidity was similar for intravenous and inhalational anaesthesia. Total intravenous anaesthesia offered advantages in postoperative recovery.
Dutch Society for Anaesthesiology (NVA).
全球每年有超过3亿外科手术患者接受全身麻醉。麻醉可通过仅使用静脉麻醉剂的全静脉麻醉或使用挥发性麻醉剂的吸入麻醉来实施。尽管已有大量已发表的试验，但关于这两种麻醉方式如何影响术后患者结局的争论仍在继续。随着人们对麻醉气体对手术环境影响的关注度不断提高，这一话题的相关性也日益增加。我们旨在总结关于全静脉麻醉与吸入麻醉对相关患者结局影响的所有现有证据。
在这项系统评价和荟萃分析中，我们检索了PubMed/Medline、Embase和Cochrane对照试验中央注册库，以查找1985年1月1日至2023年8月1日发表的比较使用丙泊酚的全静脉麻醉与使用挥发性麻醉剂七氟醚、地氟醚或异氟醚的吸入麻醉的随机对照试验。两名研究者独立筛选标题、摘要和全文文章，并使用Cochrane协作工具评估偏倚风险。结局源自最近一系列关于围手术期试验标准化终点（StEP）共识定义的出版物。主要结局包括死亡率和器官相关的发病率。次要结局与麻醉和手术相关的发病率有关。本研究已在PROSPERO注册（CRD42023430492）。
我们纳入了317项随机对照试验，共51107例患者。在院内死亡率（风险比1.05，95%置信区间0.67 - 1.66，27项试验，3846例患者）、30天死亡率（风险比0.97，95%置信区间0.70 - 1.36，23项试验，9667例患者）和一年死亡率（风险比1.14，95%置信区间0.88 - 1.48，13项试验，9317例患者）这些主要结局方面，全静脉麻醉和吸入麻醉之间未观察到差异。除老年患者亚组外，两组间器官相关发病率相似，在老年患者亚组中，全静脉麻醉与术后认知功能障碍发生率较低相关（风险比0.62，95%置信区间0.40 - 0.97，11项试验，3834例患者），且术后认知功能障碍测试得分更高（标准化均值差1.68，95%置信区间0.47 - 2.88，9项试验，4917例患者）。在次要结局方面，全静脉麻醉导致术后恶心呕吐发生率较低（风险比0.61，95%置信区间0.56 - 0.67，145项试验，23172例患者）、苏醒期谵妄较少（风险比0.40，95%置信区间0.29 - 0.56，32项试验，4203例患者）以及恢复质量评分较高（QoR - 40均值差6.45，95%置信区间3.64 - 9.25，17项试验，1835例患者）。
结果表明，静脉麻醉和吸入麻醉的术后死亡率和器官相关发病率相似。全静脉麻醉在术后恢复方面具有优势。
荷兰麻醉学会（NVA）。
