Inhalation versus intravenous anaesthesia for adults undergoing on-pump or off-pump coronary artery bypass grafting: A systematic review and meta-analysis of randomized controlled trials

Abstract

Study objective: To compare the use of inhalation versus intravenous anaesthesia for adults undergoing on-pump or off-pump coronary artery bypass grafting.

Design: A systematic review.

Setting: A hospital-affiliated university.

Measurements: The following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 10), MEDLINE, EMBASE, and LILACS (from inception to October 2016). We used the GRADE approach to rate overall certainty of the evidence.

Results: In total we included 58 studies with a total of 6105 participants. The methodological quality was difficult to assess as it was poorly reported in 35 included studies (three or more domains were rated as unclear risk of bias). Two trials of sevoflurane showed a statistically significant reduction in death within 180 to 365days of surgery (on-pump) (RR 4.10, 95% CI 1.42 to 11.79; p=0.009; I²=not applicable; high quality of evidence). There was also a statistically significant difference favouring sevoflurane compared to propofol on both inotropic (RR 2.11, 95% CI 1.53 to 2.90; p<0.00001; I²=0%) and vasoconstrictor support needed (RR 1.51, 95% CI 1.04 to 2.22; p=0.03; I²=0%) after coronary artery bypass grafting on-pump. Two trials of sevoflurane (MD -0.22, 95% CI -0.41 to -0.03; p=0.02; I²=0%) and two further trials of desflurane (MD -0.33, 95% CI -0.45 to -0.20; p<0.00001; I²=82%) showed a statistically significant difference on cardiac index during and after coronary artery bypass grafting on-pump, respectively.

Conclusions: There is high quality evidence that sevoflurane reduces death within 180 to 365days of surgery and, inotropic and vasoconstrictor support compared to propofol for patients undergoing coronary artery bypass grafting. There is also some evidence showing that the cardiac index is minimally influenced by administration of sevoflurane and desflurane compared to propofol.

Keywords: Coronary artery bypass grafting; Grade; Inhalation anaesthesia; Intravenous anaesthesia; Off-pump; On-pump; Randomized controlled trials; Systematic review.