Intravenous versus inhalational anesthesia for pediatric inpatient surgery - A systematic review and meta-analysis

General anesthesia is commonly used in pediatric inpatient surgery. It can be induced and maintained by either intravenous or volatile anesthetic agents. We aimed to elucidate whether intravenous or volatile anesthetic agents are superior with regards to preventing anesthesia-related complications.

Using a predefined standardized study protocol we conducted a systematic review of randomized controlled trials (RCTs) with meta-analysis where appropriate searching the following data bases: CENTRAL, MEDLINE, EMBASE, metaRegister of Controlled Trials (until June 2016).

We included any RCT comparing the adverse effects of intravenous or volatile anesthetic agents in pediatric inpatients. More specifically, primary endpoints were the appearance of cardiopulmonary complications or postoperative nausea and vomiting (PONV) or any cognitive dysfunction within 24 h following general anesthesia. Secondary endpoints were any other complication besides the aforementioned primary endpoints.

In total, nine RCTs (762 children) were analyzed. Regarding primary endpoints, the use of propofol during strabismus surgery significantly increased the relative risk (RR) of oculocardiac reflex (RR 4.96, 95% confidence interval [CI]: 3.13-7.87, p < 0.00001; two studies, 257 children). PONV was significantly less frequent after general anesthesia with intravenous than with volatile anesthetic agents (RR 0.68, 95% CI: 0.48-0.98, p = 0.04; five studies, 563 children). We did not find identify any further difference with regards to the predefined primary or secondary endpoints due to clinical or statistical heterogeneity.

Taken together, propofol increased the risk of oculocardiac reflex whereas PONV was less frequent following intravenous anesthetics compared to volatile anesthetics. The study results may help tailoring the use of either intravenous of volatile anesthetics onto the needs of pediatric inpatients. Given the clinical or statistical heterogeneity among the studies, we call for a scientific effort to increase the body of evidence on anesthetic agents in pediatric general anesthesia.