Inhalational Versus Propofol-based Intravenous Maintenance of Anesthesia for Emergence Delirium in Adults: A Meta-analysis and Trial Sequential Analysis

Emergence delirium (ED) is a severe postoperative complication that increases the risk for injury, self-extubation, and hemorrhage. Inhalational maintenance of anesthesia is a risk factor for ED in pediatric patients, but its impact in adults is undefined. This meta-analysis compares the incidence of ED between inhalational and propofol-based intravenous maintenance of anesthesia. Following a search of the PubMed, Medline, Embase, and Cochrane Library databases, 12 high-quality randomized controlled trials including 1440 patients, were identified for inclusion in the meta-analysis. Compared with propofol-based intravenous maintenance of anesthesia, inhalational maintenance increased the incidence of ED in adults (risk ratio [RR], 2.02; 95% confidence interval [CI]: 1.30-3.14; P=0.002). This was confirmed by sensitivity analysis, trial sequential analysis, and subgroup analyses of studies that assessed ED via Aono's four-point scale (RR, 3.72; 95% CI: 1.48-9.31; P=0.005) and the Ricker Sedation Agitation Scale (RR, 3.48; 95% CI: 1.66-7.32; P=0.001), studies that included sevoflurane for maintenance of anesthesia (RR, 1.87; 95% CI: 1.13-3.09; P=0.02), studies that reported ED as the primary outcome (RR, 2.73; 95% CI: 1.53-4.86; P=0.0007), and studies that investigated ocular (RR, 2.98; 95% CI: 1.10-8.10; P=0.03), nasal (RR; 95% CI: 1.27-6.50; P=0.01), and abdominal (RR, 3.25; 95% CI: 1.12-9.40; P=0.03) surgeries, but not intracranial surgery (RR, 0.72; 95% CI: 0.34-1.54; P=0.40). In summary, inhalational maintenance of sevoflurane was a risk factor for ED compared with propofol-based intravenous maintenance in adults who underwent ocular, nasal, and abdominal surgeries but not intracranial surgery.