Article of the Month – December 2020

A Comparison of Volatile Anesthesia and Total Intravenous Anesthesia (TIVA) Effects on Outcome From Cardiac Surgery: A Systematic Review and Meta-Analysis

URL: https://www.jcvaonline.com/article/S1053-0770(20)31150-2/fulltext

DOI: https://doi.org/10.1053/j.jvca.2020.10.036

Published: J Cardiothorac Vasc Anesth. 2020 October 21, in press.

Authors: Jamie Beverstock, Thomas Park, R. Peter Alston, Celine Chan Ah Song, Amy Claxton, Thomas Sharkey, Sarah Hutton, Joseph Fathers, Will Cawley.

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Article Description:

  • Currently, there is no consensus on the superiority of volatile anaesthetics or total intravenous anaesthetics (TIVA) on the clinical outcomes after cardiac surgery.
  • There are several published systematic reviews and meta-analyses of randomized clinical trials (RCTs) failed to demonstrate any beneficial effect of either type of anaesthesia in terms of the mortality or incidences of adverse outcomes after adult cardiac surgery.
  • Landoni et al. demonstrated no significant differences between volatile anaesthesia or TIVA regarding the 1-year mortality rate among 5,400 adult patients undergoing cardiac surgery, that study was not included in the previous systematic reviews and meta-analyses. That study might have a significant impact on the body of knowledge in the area, justifying a further systematic review and meta-analysis. [N Engl J Med 2019; 380:1214–25.]
  • The objective of this systematic review and meta-analysis was to compare the effects of TIVA and volatile anaesthesia on mortality at 30-days and 1-year after cardiac surgery in addition to the changes in the biomarkers of myocardial injury, time to tracheal extubation, and duration of intensive care unit (ICU) and hospital stays.

Summary:

  • The one-year mortality was similar between patients receiving TIVA and volatile anaesthesia (n = 6440, OR = 1.22, 95% CI 0.97 to 1.54, p = 0.09, Z = 1.67, I2 = 0%).
  • Similarly, there were no statistical differences between volatile anaesthesia and TIVA in terms of troponin (n = 3127, SMD = 0.26, 95% CI -0.01 to 0.52, p = 0.05, Z = 1.92, I2 = 90%), CK-MB concentration 24h postoperatively (n = 1214, SMD = 0.10, 95% CI -0.17 to 0.36, unadjusted p = 0.48, Z = 0.71, I2 = 79%), or time to tracheal extubation (n = 1059, SMD = 0.10, 95% CI -0.28 to 0.49, p = 0.60, Z = 0.53, I2 = 88%).
  • However, unsurprisingly, compared to TIVA group, the durations of ICU stay (n = 2003, SMD = 0.29, 95% CI 0.01 to 0.57, p = 0.04, Z = 2.05, I2 = 88%) and hospital stay (n = 1214, SMD = 0.42, 95% CI 0.10 to 0.75, p = 0.01, Z = 2.53, I2 = 91%) were shorter with using volatile anaesthetics.
  • The present study’s broader inclusion criteria to include all types of cardiac surgery suggesting the findings are more reliable.
  • There are some suggested considerations for future research comparing volatile anaesthesia and TIVA including avoidance of strict inclusion criteria specifying patient characteristics and addressing institution-specific differences in treatment policy in multicenter trials.

Conclusions:

  •  The choice of volatile anaesthesia or TIVA had no significant impact upon mortality, markers of myocardial ischaemia, or time to tracheal extubation in patients undergoing cardiac surgery.
  • However, the use of volatile anaesthesia is associated with shorter hospital and ICU stays after cardiac surgery.
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