Airway reactions and emergence times in general laryngeal mask airway anaesthesia

Abstract

BACKGROUNDDesflurane's short emergence time supports fast track anaesthesia. Data on the rate of upper airway complications and emergence time when desflurane is used with laryngeal mask airway (LMA) are controversial and limited.OBJECTIVESTo compare recovery time variables and the rates of upper airway adverse events in patients with an LMA undergoing general surgery with desflurane, sevoflurane, isoflurane or propofol anaesthesia.DESIGNA systematic review and meta-analysis of randomised controlled trials (RCTs).DATA SOURCESA systematic search for eligible RCTs in Embase (Elsevier) and in PubMed (National Library of Medicine) databases up to September 2013.ELIGIBILITY CRITERIARCTs investigating the rates of cough overall, cough at emergence, laryngospasm, time to eye opening, time to removal of the LMA, time to respond to command and time to state date of birth in patients with an LMA, during emergence from desflurane, sevoflurane, isoflurane or propofol anaesthesia.RESULTSThirteen RCTs were included and analysed. We found a strong interstudy variability. There was no difference in the rates of upper airway events between desflurane and sevoflurane or between desflurane and a control group consisting of all the other anaesthetics combined. Comparing desflurane (n = 284) with all other anaesthetic groups (n = 313), the risk ratio [95% confidence interval (95% CI)] was 1.12 (0.63 to 2.02, P = 0.70). Cough at emergence was only measured in patients receiving desflurane (n = 148) and sevoflurane (n = 146): the risk ratio (95% CI) was 1.49 (0.55 to 4.02, P = 0.43). Laryngospasm was rare and there was no significant difference in its incidence when desflurane (n = 262) was compared with all other anaesthetics combined (n = 289; risk ratio 1.03; 95% CI 0.33 to 3.20, P = 0.96). The times of all emergence variables were significantly faster in the desflurane group than in all other groups.CONCLUSIONWhen using an LMA, upper airway adverse reactions in association with desflurane anaesthesia were no different from those noted with sevoflurane, isoflurane or propofol anaesthesia. Emergence from general anaesthesia with desflurane is significantly faster than all the other anaesthetics. Due to interstudy variations and the small size of the trials, further large-scale, multicentre studies are required to confirm or refute the results of this meta-analysis.

Prolonged patient emergence time among clinical anesthesia resident trainees

“…[318] Consistent with recent meta-analyses, we found that desflurane or sevoflurane use was associated with lower rates of prolonged patient emergence time versus isoflurane. [12131920]…”

“…Of note, laryngospasm incidence does not change with the type of inhaled anesthetic administered. [20] The authors cannot exclude the possibility that unconsidered covariates, such as the history of anesthetic complications, documented difficult intubation, obstructive sleep apnea, and others may have exerted an effect on emergence time.…”

“…We utilized electronic medical record data, which included time to endotracheal extubation. Other efforts have employed time to open eyes, time to state the date of birth, and time to recover prior functional capacity after 1 day of surgery[20] to assess emergence time. Moreover, the interval between the end of surgery and patient wake up is reported varyingly: Some studies start timing at the end of anesthetic delivery,[21] some at surgical closure and others do not specify.…”

Statistical analysis methods for meta-analysis of times to emergence

“…3 Meta-analysis was performed by using generalised pivotal methods. 3,5 We recommend caution in relying on the accuracy of coverage, or meaningfulness of interpretation, of the confidence intervals for the recovery times in Stevanovic et al 1 Based on our statistical developments, 3,4 what are the authors' perspectives?…”

“…Stevanovic et al 1 performed a meta-analysis comparing multiple endpoints between desflurane and other general anaesthetic agents including sevoflurane, isoflurane and propofol. They limit consideration to patients with laryngeal mask airway.…”