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Review
. 2018 Aug 21;8(8):CD012317.
doi: 10.1002/14651858.CD012317.pub2.

Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery

David Miller  1 , Sharon R Lewis, Michael W Pritchard, Oliver J Schofield-Robinson, Cliff L Shelton, Phil Alderson, Andrew F Smith
Affiliations
Review

Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery

David Miller et al. Cochrane Database Syst Rev. .

Abstract

Background: The use of anaesthetics in the elderly surgical population (more than 60 years of age) is increasing. Postoperative delirium, an acute condition characterized by reduced awareness of the environment and a disturbance in attention, typically occurs between 24 and 72 hours after surgery and can affect up to 60% of elderly surgical patients. Postoperative cognitive dysfunction (POCD) is a new-onset of cognitive impairment which may persist for weeks or months after surgery.Traditionally, surgical anaesthesia has been maintained with inhalational agents. End-tidal concentrations require adjustment to balance the risks of accidental awareness and excessive dosing in elderly people. As an alternative, propofol-based total intravenous anaesthesia (TIVA) offers a more rapid recovery and reduces postoperative nausea and vomiting. Using TIVA with a target controlled infusion (TCI) allows plasma and effect-site concentrations to be calculated using an algorithm based on age, gender, weight and height of the patient.TIVA is a viable alternative to inhalational maintenance agents for surgical anaesthesia in elderly people. However, in terms of postoperative cognitive outcomes, the optimal technique is unknown.

Objectives: To compare maintenance of general anaesthesia for elderly people undergoing non-cardiac surgery using propofol-based TIVA or inhalational anaesthesia on postoperative cognitive function, mortality, risk of hypotension, length of stay in the postanaesthesia care unit (PACU), and hospital stay.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 11), MEDLINE (1946 to November 2017), Embase (1974 to November 2017), PsycINFO (1887 to November 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.

Selection criteria: We included randomized controlled trials (RCTs) with participants over 60 years of age scheduled for non-cardiac surgery under general anaesthesia. We planned to also include quasi-randomized trials. We compared maintenance of anaesthesia with propofol-based TIVA versus inhalational maintenance of anaesthesia.

Data collection and analysis: Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesized findings.

Main results: We included 28 RCTs with 4507 randomized participants undergoing different types of surgery (predominantly cardiovascular, laparoscopic, abdominal, orthopaedic and ophthalmic procedures). We found no quasi-randomized trials. Four studies are awaiting classification because we had insufficient information to assess eligibility.All studies compared maintenance with propofol-based TIVA versus inhalational maintenance of anaesthesia. Six studies were multi-arm and included additional TIVA groups, additional inhalational maintenance or both. Inhalational maintenance agents included sevoflurane (19 studies), isoflurane (eight studies), and desflurane (three studies), and was not specified in one study (reported as an abstract). Some studies also reported use of epidural analgesia/anaesthesia, fentanyl and remifentanil.We found insufficient reporting of randomization methods in many studies and all studies were at high risk of performance bias because it was not feasible to blind anaesthetists to study groups. Thirteen studies described blinding of outcome assessors. Three studies had a high of risk of attrition bias, and we noted differences in the use of analgesics between groups in six studies, and differences in baseline characteristics in five studies. Few studies reported clinical trials registration, which prevented assessment of risk of selective reporting bias.We found no evidence of a difference in incidences of postoperative delirium according to type of anaesthetic maintenance agents (odds ratio (OR) 0.59, 95% confidence interval (CI) 0.15 to 2.26; 321 participants; five studies; very low-certainty evidence); we noted during sensitivity analysis that using different time points in one study may influence direction of this result. Thirteen studies (3215 participants) reported POCD, and of these, six studies reported data that could not be pooled; we noted no difference in scores of POCD in four of these and in one study, data were at a time point incomparable to other studies. We excluded one large study from meta-analysis because study investigators had used non-standard anaesthetic management and this study was not methodologically comparable to other studies. We combined data for seven studies and found low-certainty evidence that TIVA may reduce POCD (OR 0.52, 95% CI 0.31 to 0.87; 869 participants).We found no evidence of a difference in mortality at 30 days (OR 1.21, 95% CI 0.33 to 4.45; 271 participants; three studies; very low-certainty evidence). Twelve studies reported intraoperative hypotension. We did not perform meta-analysis for 11 studies for this outcome. We noted visual inconsistencies in these data, which may be explained by possible variation in clinical management and medication used to manage hypotension in each study (downgraded to low-certainty evidence); one study reported data in a format that could not be combined and we noted little or no difference between groups in intraoperative hypotension for this study. Eight studies reported length of stay in the PACU, and we did not perform meta-analysis for seven studies. We noted visual inconsistencies in these data, which may be explained by possible differences in definition of time points for this outcome (downgraded to very low-certainty evidence); data were unclearly reported in one study. We found no evidence of a difference in length of hospital stay according to type of anaesthetic maintenance agent (mean difference (MD) 0 days, 95% CI -1.32 to 1.32; 175 participants; four studies; very low-certainty evidence).We used the GRADE approach to downgrade the certainty of the evidence for each outcome. Reasons for downgrading included: study limitations, because some included studies insufficiently reported randomization methods, had high attrition bias, or high risk of selective reporting bias; imprecision, because we found few studies; inconsistency, because we noted heterogeneity across studies.

Authors' conclusions: We are uncertain whether maintenance with propofol-based TIVA or with inhalational agents affect incidences of postoperative delirium, mortality, or length of hospital stay because certainty of the evidence was very low. We found low-certainty evidence that maintenance with propofol-based TIVA may reduce POCD. We were unable to perform meta-analysis for intraoperative hypotension or length of stay in the PACU because of heterogeneity between studies. We identified 11 ongoing studies from clinical trials register searches; inclusion of these studies in future review updates may provide more certainty for the review outcomes.

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Conflict of interest statement

David Miller: Funded Health Education England internship for the clinical academic programme. This was a six month part time funded post, 30 days in total, to allow an introduction into all aspects and roles across clinical academic research. The internship is designed to provide dedicated time to gain an understanding of the world of health research (Sources of support)

Cliff Shelton has received an NIHR award (DRF‐2015‐08‐208) to fund a qualitative research project investigating anaesthesia for hip fracture surgery as part of his doctoral research fellowship at Lancaster University

Sharon R Lewis see Sources of support

Michael Pritchard: see Sources of support

Oliver Schofield‐Robinson see Sources of support.

Phil Alderson: work on this review is funded, in part, by a UK NIHR Cochrane programme grant for the preparation of reviews relevant to recovery from critical illness (Sources of support)

Andrew F Smith: see Sources of support

See Sources of support

Figures

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1
Study flow diagram
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
See this image and copyright information in PMC

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References

References to studies included in this review

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Schilling 2011 {published data only}
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Shao 2013 {published data only}
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Sohn 2008 {published data only}
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Sugata 2012 {published data only}
    1. Sugata A, Hayashi H, Kawaguchi M, Hasuwa K, Nomura Y, Furuya H. Changes in intraocular pressure during prone spine surgery under propofol and sevoflurane anesthesia. Journal of Neurosurgical Anesthesiology 2012;24(2):152‐6. [PUBMED: 22274735] - PubMed
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Tufano 2000 {published data only}
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Ueda 1999 {published data only}
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Wakabayashi 2014 {published data only}
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Yu 2010a {published data only}
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Zabolotskikh 2013 {published data only}
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References to studies awaiting assessment

IRCT2015112925277N1 {published data only}
    1. IRCT2015112925277N1. Comparison intravenous anesthesia with propofol and inhalation anesthesia with Isoflurane for pain measurement in post operative patients after inguinal herniorrhaphy. en.irct.ir/trial/21168 (first received 24 December 2015).
McDonagh 2012 {published data only}
    1. McDonagh D, Attix D, Pieper C, Martin G, Monk T. Preoperative cognitive status, not type of general anesthesia, predicts early postoperative cognitive dysfunction. Journal of Neurosurgical Anesthesiology 2012;24(4):493.
NCT02766062 {published data only}
    1. NCT02766062. Effects of propofol and sevoflurane on early POCD in elderly patients with metabolic syndrome. clinicaltrials.gov/ct2/show/NCT02766062 (first received 9 May 2016).
Shen 2011 {published data only}
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References to ongoing studies

ChiCTR‐IOR‐16009851 {published data only}
    1. ChiCTR‐IOR‐16009851. Impact of postoperative cognitive function after sevoflurane‐ or propofol‐aneasthesia in aged cancer patients: a double‐blinded randomized controlled trial. www.chictr.org.cn/hvshowproject.aspx?id=10508 (first received 14 November 2016).
EUCTR2014‐004604‐29‐DK {published data only}
    1. EUCTR2014‐004604‐29‐DK. Sevoflurane versus standard general anesthesia in elective open abdominal aortic aneurism surgery. www.clinicaltrialsregister.eu/ctr‐search/trial/2014‐004604‐29/DK (first received 3 April 2015).
NCT01809041 {published data only}
    1. NCT01809041. Comparison of intravenous anesthetics to volatile anesthetics on postoperative cognitive dysfunction [Comparison of total intravenous anesthesia with sevoflurane‐based balanced anesthesia on postoperative cognitive dysfunction in elderly patients for major elective intra‐abdominal surgery]. clinicaltrials.gov/ct2/show/record/NCT01809041 (first received 6 March 2013).
NCT01995214 {published data only}
    1. NCT01995214. Sevoflurane and propofol anesthesia on postoperative delirium [Comparison of sevoflurane and propofol anesthesia on postoperative delirium in geriatric patients]. clinicaltrials.gov/ct2/show/record/NCT01995214 (first received 13 November 2013).
NCT02107170 {published data only}
    1. NCT02107170. Effects of anesthetics on postoperative cognitive function of patients undergoing endovascular repair of aortic aneurysm and endovascular treatment of arteriosclerosis obliterans of lower extremities [Comparison of intravenous anesthetics and volatile anesthetics on postoperative cognitive dysfunction of patients undergoing endovascular repair of aortic aneurysm and endovascular treatment of arteriosclerosis obliterans of lower extremities]. clinicaltrials.gov/ct2/show/record/NCT02107170 (first received 25 March 2014).
NCT02133638 {published data only}
    1. NCT02133638. Sevoflurane decreases the risk of postoperative delirium after cerebral hypoxemia during surgery [Sevoflurane‐based volatile induction and maintenance of anaesthesia (VIMA) strategy decreases the risk of postoperative delirium in elderly patients with registered cerebral hypoxemia episodes during general surgery]. clinicaltrials.gov/ct2/show/record/NCT02133638 (first received 6 May 2014).
NCT02301676 {published data only}
    1. NCT02107170. Long term postoperative cognitive dysfunction in the elderly patients [Phase 4 study of long term postoperative cognitive dysfunction after laparoscopic cholecystectomy in the elderly patients]. clinicaltrials.gov/ct2/show/record/NCT02301676 (first received 8 October 2014).
NCT02458547 {published data only}
    1. NCT02458547. Effect of anesthesia technique on outcome after hip fracture surgery in elderly adult patients. clinicaltrials.gov/ct2/show/record/NCT02458547 (first received 26 May 2015).
NCT02662257 {published data only}
    1. NCT02662257. Impact of anesthesia maintenance methods on incidence of postoperative delirium [Impact of inhalational versus intravenous anesthesia maintenance methods on incidence of postoperative delirium in elderly patients after cancer surgery: an open‐label, randomized controlled trial]. clinicaltrials.gov/ct2/show/record/NCT02662257 (first received 5 January 2016).
NCT03165396 {published data only}
    1. NCT03165396. Appropriate compatibility of propofol and sevoflurane for orthopaedic surgery of patients with MCI [The appropriate compatibility of propofol and sevoflurane for orthopaedic surgery of patients with mild cognitive impairment]. clinicaltrials.gov/ct2/show/record/NCT03165396 (first received 17 May 2017).
NCT03194074 {published data only}
    1. NCT03194074. Early cognitive function in elderly patients after laser laryngeal surgery: des vs prop [Early cognitive function and recovery in elderly patients after laser laryngeal surgery: desflurane‐based vs propofol‐based anesthesia]. clinicaltrials.gov/ct2/show/record/NCT03194074 (first received 17 June 2017).

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References to other published versions of this review

Miller 2016
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MeSH terms

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