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Intravenous versus inhalational anaesthesia for paediatric outpatient surgery

  1. Ana C Ortiz1,*,
  2. Álvaro N Atallah2,
  3. Delcio Matos3,
  4. Edina MK da Silva4

Editorial Group: Cochrane Anaesthesia Group

Published Online: 7 FEB 2014

Assessed as up-to-date: 1 OCT 2013

DOI: 10.1002/14651858.CD009015.pub2


How to Cite

Ortiz AC, Atallah ÁN, Matos D, da Silva EMK. Intravenous versus inhalational anaesthesia for paediatric outpatient surgery. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD009015. DOI: 10.1002/14651858.CD009015.pub2.

Author Information

  1. 1

    Universidade Federal de São Paulo, Department of Surgery/ Discipline of Anesthesiology, São Paulo, São Paulo, Brazil

  2. 2

    Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde, Brazilian Cochrane Centre, São Paulo, São Paulo, Brazil

  3. 3

    Escola Paulista de Medicina, Universidade Federal de São Paulo, Gastroenterological Surgery, São Paulo, São Paulo, Brazil

  4. 4

    Universidade Federal de São Paulo, Emergency Medicine and Evidence Based Medicine, São Paulo, São Paulo, Brazil

*Ana C Ortiz, Department of Surgery/ Discipline of Anesthesiology, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5th floor, São Paulo, São Paulo, 04024002, Brazil. ortizcarol@hotmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 7 FEB 2014

SEARCH

 
Characteristics of included studies [ordered by study ID]
Annila 1999

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 90 children
Generation of allocation: Each child was randomly allocated by computer-based random listing to one of three groups. Blinded assessment of treatment allocation: the Holter-ECG recordings were analysed separately by a physician who was unaware of the induction method. Withdrawals:reported four patients.The Holter-ECG recordings were not readable due to technical disturbances in two patients in groups PA and H. Follow up: The study period extended from the application of the Holter-ECG leads until 3min after tracheal intubation, after which anaesthesia was continued in accordance with the preferences of the consultant anaesthetist.


Participants90 patients. Sex: Group TS -15 male and 15 female; Group PA - 17 male and 13 female; Group H - 19 male and 11 female. Age (mean): Group TS - 1.9 years; Group PA - 2.1 years; Group H - 2.0 years. Inclusion criteria: children (ASA I-II) aged 1–3 years undergoing adenoidectomy in the ENT unit participated in the study. Exclusion criteria: not reported


InterventionsIn group TS, the anaesthesia was induced with thiopentone and suxamethonium; In group PA, was with alfentanil and propofol and group H was induced using 5 vol% inspired halothane with 70% nitrous oxide in oxygen with facemask

In all groups after tracheal intubation, anaesthesia was maintained with 1–3 vol% halothane with 70% nitrous oxide in oxygen delivered via a Bain coaxial breathing system


OutcomesThe incidence of dysrhythmias (supraventricular extrasystole, bradycardia) and desaturation (less than 92%) during induction of anaesthesia


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Each child was randomly allocated by computer based random listing to one of three groups"

Allocation concealment (selection bias)Unclear riskComment: no information provided

Blinding of participants and personnel (performance bias)
All outcomes
Low riskQuote: "Tracheal intubation was always preformed by the same senior anaesthetist , who was unaware of the induction method"

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "the Holter-ECG recordings were analysed separately by a physician who was unaware of the induction method."

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "The Holter-ECG recordings were not readable due to technical disturbances in two patients in groups PA and H"

Selective reporting (reporting bias)Low riskQuote:"Outcomes: The incidence of dysrhythmias( supraventricular extrasystole,bradycardia) and desaturation (less than 92%)during induction of anaesthesia."

Other biasLow riskComment: the study appears to be free of other sources of bias

Baykara 1998

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 40 children
Generation of allocation: not reported. Allocation concealment: not reported. Blinded assessment of treatment allocation: not reported. Withdrawals: none. Follow up: The time of discharge and time of extubation were recorded. The incidence of side effects (laryngospasm, agitation, vomiting) were recorded in the recovery room and the incidence of vomiting was recorded 24hrs after surgery


Participants40 patients. Sex: Group propofol - 15 male and 5 female; Group sevoflurane - 14 male and 6 female. Age (mean): Group Propofol - 6.54 years; Group sevoflurane - 6.6 years. Inclusion criteria: children, ASA I, aged 3–12 years undergoing tonsillectomy and\or adenoidectomy outpatient surgery. Exclusion criteria: not reported


InterventionsGroup Propofol: induction was achieved with propofol and maintained by propofol + 60% N2O

Group Sevoflurane: induction was achieved with 4-7% sevoflurane + 60% N2O and anaesthesia was maintained by 2-3% sevoflurane + 60% N2O


OutcomesTime to extubation

Time to discharge from hospital

Time to discharge from recovery room

The incidence of side effects during recovery:

  • Laryngospasm
  • Agitation


The incidence of vomiting:

  • In the recovery room
  • 24hrs after surgery


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: no information provided

Allocation concealment (selection bias)Unclear riskComment: no information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
High riskComment: probably not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)High riskComment: the study did not describe the definition of postoperative agitation

Other biasLow riskComment: the study appears to be free of other sources of bias

Borgeat 1990

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 40 children. Generation of allocation: Children were randomly allocated in an open study to either group A (propofol) or group B (thiopental/halothane). Allocation concealment: not reported. Blinded assessment of treatment allocation: not reported. Follow up: interval between end of drug administration and extubation and discharge from the recovery room


Participants40 patients. Sex: Group propofol - 9 male and 11 female; Group Thiopental/halothane - 8 male and 12 female. Age (mean): Group Propofol - 6.09 years and Group Thiopental\Halothane - 5.11 years. Inclusion criteria: children (ASA I) aged 3-8 years undergoing short elective ENT procedures participated in the study. Exclusion criteria: included known allergy to the anaesthetic drugs or their constituents, a history of previous adverse experience to general anaesthesia, the presence of psychomotor retardation, and general anaesthesia with halothane within the last 3 months


InterventionsIn group A (propofol), the anaesthesia was induced with propofol and immediately followed by a continuous infusion of propofol and N2O 66% and in Group B (Thiopental\Halothane) patients were given thiopental with maintenance of anaesthesia provided by halothane (0.5%-1.5%) + N2O 66%


OutcomesTime to extubation (minutes): the interval between the end of the administration of propofol or halothane and extubation

Time to discharge from recovery room (minutes): the time between the end of the administration of propofol or halothane and the completion of the criteria for discharge from the recovery room

The incidence of postoperative nausea and vomiting


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Children were randomly allocated in an open study to either group A (propofol) or group B (thiopental/halothane)."

Comment: I do not know  if it was done

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
High riskComment: probably not done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)Low riskOutcomes: "Time to extubation (minutes): the interval between the end of the administration of propofol or halothane and extubation; time to discharge from recovery room (minutes): the time between the end of the administration of propofol or halothane and the completion of the criteria for discharge from the recovery room and the incidence of postoperative nausea and vomiting."

Other biasLow riskComment: the study appears to be free of other sources of bias

Cohen 2003

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 53 children. Generation of allocation: not reported. Blinded assessment of treatment allocation: an observer blinded to the anaesthetic technique recorded degree of agitation. Withdrawals: none. Follow up: The degree of agitation was recorded in the Postanaesthesia Care Unit (PACU). The time to extubation was recorded. Parents were contacted 24 hours after surgery to follow up on the incidence of agitation and pain at home


Participants53 patients. Age (mean): Group Propofol - 15.3 months; Group Sevoflurane - 12.9 months. Gender: Group Propofol - 18\8; Group Sevoflurane 18\9. Inclusion criteria: healthy children, aged 2-36 months, ASA Physical Status I or II scheduled for ambulatory surgical procedures. Exclusion criteria: less than 40 weeks postconceptional age, signs of developmental delay


InterventionsThe anaesthesia was induced with 60% N2O and 8% sevoflurane in all cases

Group Propofol (27 participants): anaesthesia was maintained with propofol and 60% N2O

Group Sevoflurane (26 participants): anaesthesia was maintained with sevoflurane (1.5 to 2.5%) and 60% N2O


OutcomesTime to extubation

Degree of agitation: scored on a 3-point scale

1 = calm

2 = agitated but consolable

3 = severely agitated, inconsolable

The incidence of vomiting in the recovery room

Time to discharge from the PACU


NotesAnalgesia was supplied by either a caudal block with bupivacaine 0.25% or fentanyl ,according to surgical procedure. There was no significant difference between the sevoflurane and propofol groups in the type of analgesia technique that was used during surgery


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote:"...were randomized to receive sevoflurane or propofol for maintenance anaesthesia."

Comment: I do not know if it was done

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...an observer blinded to the anaesthetic technique recorded degree of agitation..."

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)High riskThe pre-specified "Time to discharge from the PACU" outcome was not reported in the results

Other biasLow risk Comment: the study appears to be free of other sources of bias

Cohen 2004

MethodsDesign: randomized, open-label, comparative, parallel-group study. Single-centre. Period: not reported. Sample size: 56 children. Generation of allocation:not reported. Blinded assessment of treatment allocation:assessment was performed by investigator blinded to the anaesthetic technique. Withdrawals:none. Follow up:the time to extubation and time to complete recovery were recorded.In addition,measurement of ionised calcium and ionised magnesium concentrations were collected at baseline; at 5, 10, 15 and 30 min during anaesthesia; at the end of study drug administration and 30 min after the end of anaesthesia and telephone contact was made with the parents after 24 hours to determine if any adverse events occurred after discharge


Participants56 patients. Age (mean): Group Propofol - 14.7 months; Group Sevoflurane - 13.2 months. Inclusion criteria: children younger than 3 years of age classified under ASA Physical Status I or II scheduled for ambulatory surgical procedures Exclusion criteria: not reported


InterventionsIn all patients, anaesthesia was induced with nitrous oxide (60%), oxygen and sevoflurane (8%)

Group Propofol: the anaesthesia was maintained with propofol and nitrous oxide 60%
Group Sevoflurane: the anaesthesia was maintained with sevoflurane (1.5-2.5%) + nitrous oxide 60%


OutcomesTime to extubation

Measurement of ionised calcium and ionised magnesium concentrations: were collected at baseline; at 5,10,15 and 30 min during anaesthesia; at the end of study drug administration and 30 minutes after the end of anaesthesia

The incidence of postoperative vomiting


NotesPatients undergoing lower body procedures received a caudal block with 0.25% bupivacaine and patients undergoing eye and airway surgeries received fentanyl. The use of regional blocks and fentanyl was comparable between the propofol and sevoflurane groups


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "...were randomly assigned to receive either propofol or sevoflurane."

Comment: I do not know if it was done

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Assessment (time to extubation and time to complete recovery) was performed by investigator blinded to the anaesthetic technique"

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasLow riskComment: the study appears to be free of other sources of bias

Crawford 1998

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 60 children
Generation of allocation: "They were assigned using a table of random numbers to one of three anaesthetic regimens". Blinded assessment of treatment allocation:"postoperative data were gathered by an investigator who was unaware of the anaesthetic regimen administered".Withdrawals:data from six children who received regional anaesthesia after induction of anaesthesia were excluded from the analysis.Follow up:recovery scores were assessed on arrival in the PACU and at 5,10,20,30,40,50 and 60 minutes after the end of anaesthesia.The incidence of emesis were determined both in the PACU and for the first 24h after discharge


Participants54 patients. Age (mean): Group Propofol- 6.7 years; Group Propofol+N2O -6.2 years; Group Thio\Halothane -6.1 years. Inclusion criteria: children aged 3-12 years presenting for elective outpatient surgery lasting approximately one hour. Exclusion criteria: if they had a history of cardiorespiratory, gastrointestinal or central nervous system disease, or if they requested either premedication or an inhalational induction


InterventionsGroup Propofol: anaesthesia with propofol

Group Propofol + N20 : propofol and N2O 70%

Group Thiopental\Halothane: thiopental followed by halothane and N2O 70% in oxygen for maintenance


OutcomesThe incidence of postoperative emesis:

  • In the PACU
  • 24h after discharge


Time to extubation: time from discontinuation of anaesthetic until extubation of the trachea

Time to discharge from PACU: time from discontinuation of anaesthetic until full recovery (modified Aldrete score ≥ 8)


NotesWhen appropriate, ilioinguinal\iliohypogastric nerve blocks (bupivacaine 0,25%) were administered at the end of surgery. There were no statistically significant differences in the number of children who received iliohypogastric\ilioinguinal nerve blocks


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "They were assigned using a table of random numbers to one of three anaesthetic regimens"

Comment: done

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Postoperative data were gathered by an investigator who was unaware of the anaesthetic regimen administered"

Comment: done

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Data from six children who received regional anaesthesia after induction of anaesthesia were excluded from the analysis"

Comment: missing outcome data have similar reasons

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasLow riskComment: the study appears to be free of other sources of bias

Glaisyer 2005

MethodsDesign: the study design was single-blind. Single-centre. Period: not reported. Sample size: 21 children
Generation of allocation: "For the first procedure, children were randomized to receive one of two anaesthetic techniques; the other technique was used subsequently and both techniques were therefore studied by within-patient comparisons". Blinded assessment of treatment allocation:"children, parents, and recovery staff were unaware which technique had been used, but, during the procedure itself, the two anaesthetic techniques could not be disguised". Withdrawals: Only eight participants were evaluated at the time which were children ready for discharge from the hospital. Follow up: The primary outcome variable was the time taken to achieve recovery discharge criteria after the end of procedure. In the recovery room, distress behaviour, bradycardia, oxygen saturations < 94% were assessed


Participants21 patients. The mean age of the patients was 6 years and 6 months. Inclusion criteria: children, aged 2 to 10 years, were recruited if they were scheduled to undergo 2 similar painful procedures separated by no more than 2 week. Exclusion criteria:Patients were excluded if they were ASA physical status grade III, were unable to respond appropriately to verbal commands, or if they had been in pain, been nauseated, or received sedative or analgesic medication within the previous 12 hours


InterventionsIn all groups, anaesthesia was induced with propofol

Anaesthesia was maintained either by:

Group PR: remifentanil with propofol

Group PSN: inhaled sevoflurane with nitrous oxide 66%


OutcomesDistress behaviour was assessed using a simple scoring system, modified from that of Hannallah 1987, in which crying, moving and agitation were scored separately (0, 1, or 2, maximum distress score 6) in the recovery room

The incidence of nausea or\and vomiting in the recovery room

The time at which children were ready for discharge from the recovery ward (after the end of procedure) was recorded

Bradycardia (< 60 beats/min) occurred during recovery

Desaturation:oxygen saturations < 94% during or after anaesthesia


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "For the first procedure, children were randomized to receive one of two anaesthetic techniques; the other technique was used subsequently and both techniques were therefore studied by within-patient comparison"

Comment: Insufficient information about the sequence generation

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskQuote: "Children, parents, and recovery staff were unaware which technique had been used, but, during the procedure itself, the two anaesthetic techniques could not be disguised"

Comment: Probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Children, parents, and recovery staff were unaware which technique had been used, but, during the procedure itself, the two anaesthetic techniques could not be disguised"

Comment: Problably done

Incomplete outcome data (attrition bias)
All outcomes
High riskOnly eight participants were evaluated at the time which they were ready for discharge from the hospital

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasHigh riskQuote: "...the behavior of children varies from day to day and, as an example, one child who was disturbed after propofol was calm on subsequent occasions with the same technique."

Comment: Probably done

Guard 1998

MethodsDesign: RCT. Single centre. Period: not reported. Sample size: 50 children
Generation of allocation: "Randomization was achieved using random number tables prepared in advance of commencing the study". Blinded assessment of treatment allocation:the data were recorded by a research nurse who was blinded to the anaesthetic assignment. Withdrawals:none. Follow up: During postoperative recovery, time to extubation and time to recovery were recorded. All adverse events during emergence (haemoglobin oxygen desaturation and vomiting) and recovery (pain and vomiting) until discharge from hospital were recorded. On the day after surgery, the children's parents were interviewed by phone to determine the presence of adverse events (nausea and vomiting)


Participants50 patients. Sex: Group Sevoflurane - 23 male and 2 female; Group Propofol - 22 male and 3 female. Age (mean): Group Sevoflurane - 4.6 years and Group Propofol - 4.2 years. Inclusion criteria:children, ASA I-II, two to eight years of age, fasted, scheduled for urological surgery as outpatients Exclusion criteria: not reported


InterventionsGroup Sevoflurane: anaesthesia was induced using stepwise increases in the inspired concentration of sevoflurane
(2% increments every two breaths to a maximum inspired concentration of 8%) and N2O 70% and was maintained with an end-tidal sevoflurane concentration of 2.5% + N2O 70%;

Group Propofol: anaesthesia was with propofol and N2O 70%


OutcomesHaemoglobin oxygen desaturation < 90%:

  • during emergence
  • during recovery


Laryngospasm, bronchospasm, excitation:

  • during emergence


Vomiting:

  • during emergence
  • during recovery until discharge from hospital
  • day after surgery (24h)


Time to extubation: the interval from discontinuation of the anaesthetic until extubation

Time to recovery: time from discontinuation of the anaesthetic to eligibility for discharge from the recovery room (defined as a modified Aldrete score of 8)

Time to discharge from hospital: time from discontinuation of anaesthetic to eligibility for discharge from the hospital


Notes"Before surgical incision, a lumbar or caudal epidural block was established in all children using bupivacaine 0.175% without epinephrine."


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Randomization was achieved using random number tables prepared in advance of commencing the study."

Comment: probably done

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...were recorded by a research nurse who was blinded to the anaesthetic assignment."

Comment: probably done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasHigh riskQuote: "The relatively small incidence of postoperative vomiting in this study may be attributed to the avoidance of gastric inflation before tracheal intubation, the opioid-sparing action of the epidural blocks and the postanaesthetic policy of elective oral fluid administration."

Comment: probably done

Gurkan 1999

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 40 children. Generation of allocation: "patients were randomly allocated (using a random number table) to two groups of 20 patients". Blinded assessment of treatment allocation:"the timing of each vomiting episode, was recorded by a blinded nurse observer". Withdrawals: none. Follow up: "...during anaesthesia and postoperative until the day after surgery (at home). The parents were contacted the day after surgery by a blinded nurse and reported vomiting or any other surgical or anaesthesia-related problems."


Participants40 patients. Sex: Group 1 - 11 male and 9 female; Group 2 - 13 male and 7 female. Age (mean): Group 1 - 8 years and Group 2 - 8 years. Inclusion criteria: children aged 3-15 years, ASA I presenting for strabismus surgery. Exclusion criteria: patients were excluded if they had an allergy to any of the drugs to be used or they had a symptomatic medical illness


InterventionsIn group 1, the anaesthesia was induced with propofol, and maintained with a propofol and N2O 66%. In group 2, anaesthesia was induced and maintained with N2O 66% and sevoflurane


OutcomesThe incidence of nausea and\or vomiting before the patient left Postanaesthesia Care Unit (PACU), before discharge from the hospital and the day after surgery.

The incidence of oculo cardiac reflex: defined as an acute decrease in heart rate of 20% or greater associated with traction on an eye muscle

The incidence of agitation in the PACU

Bradycardia during induction


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Patients were randomly assigned using a table of random numbers to 2 groups of 20 patients."

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The timing of each vomiting episode,was recorded by a blinded nurse observer."

Comment: probably done

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)High riskComment: to evaluate the presence of agitation, did not include any score

Other biasLow riskComment: the study appears to be free of other sources of bias

Hannallah 1994

MethodsDesign: open, comparative, parallel, randomized study. Single-centre. Period: not reported. Sample size: 100 children. Generation of allocation: "... were randomized to receive one of four possible induction/maintenance combinations". Allocation concealment: not reported. Blinded assessment of treatment allocation: "Recovery from anaesthesia was objectively evaluated in the Post Anaesthesia Care Unit (PACU) by a research nurse, who was not aware of the anaesthetic sequence". Withdrawals: 18 patients were not evaluated regarding for the incidence of vomiting at home. Follow up: The time to induction, time to extubation, time to recovery from PACU were recorded. The incidence of vomiting in the hospital and at home (24hrs after surgery)


Participants100 patients. Age (mean): Group 1 - 7.6 years and Group 2- 7.1 years; Group 3 - 6.3 years; Group 4 - 5.2 years. Inclusion criteria: children, ASA I or II, 3-12 years old undergoing ambulatory surgical procedures. Exclusion criteria: not recorded


InterventionsGroup 1 (PROP/PROP) received propofol
Group 2 (PROP/HAL) received propofol and halothane 0.5-2% inspired concentration

Group 3 (THIO/HAL) received thiopentone and halothane 0.5-2%

Group 4 (HAL/HAL) received halothane for both anaesthesia induction and maintenance

Nitrous oxide (60-70%) was combined with oxygen as the carrier gases in all cases


OutcomesThe incidence of hypotension (defined as two consecutive systolic blood pressure readings that were at least 20% below baseline) during the anaesthesia induction and maintenance

Time to induction of anaesthesia

Time to extubation: was calculated from the moment propofol or halothane was turned off until tracheal extubation

Time to recovery: time from discontinuation of anaesthetic agents to reach a score of six on the Steward recovery scale. The Steward recovery scale is based on assessment of three criteria (consciousness, airway, and movement), where a score of 0 to 2 is assigned to each criterion with a maximum total score of 6 when the child is fully awake

The incidence of nausea or vomiting:

  • in the hospital
  • at home ( 24hrs after surgery)


Notes"At the conclusion of surgery, bupivacaine 0.25% was infiltrated around the incision site when appropriate..."


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "... were randomized to receive one of four possible induction/maintenance combinations."

Comment: I do not know if it was done

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Recovery from anaesthesia was objectively evaluated in the Post Anaesthesia Care Unit (PACU) by a research nurse, who was not aware of the anaesthetic sequence..."

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "The incidence of vomiting at home for the 82 patients who were successfully contacted by phone 24 hr after surgery..."

Comment: it does not describe if the loss to follow up of postoperative vomiting was similar in the groups

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasLow riskComment: the study appears to be free of other sources of bias

Madan 2001

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 55 children. Generation of allocation: they were randomly allocated (using a random number table) to receive either TIVA with propofol (group P) or inhalational anaesthesia using halothane in 70% nitrous oxide and oxygen (group H). Blinded assessment of treatment allocation: recovery was assessed by the recovery room nurse (independent, blinded). Withdrawals: none. Follow up: until discharge from the recovery area


Participants55 patients. Sex: Group P(propofol) - 16 male and 13 female; Group H (halothane) - 14 male and 12 female. Age (mean): Group P - 2.36 years and Group H - 2.42 years. Inclusion criteria: children aged less than 5 years, ASA I or II, presenting for non-invasive diagnostic ophthalmic procedures. Exclusion criteria were: respiratory tract infection, difficult airway, congenital abnormalities, increased intracranial or intraocular pressure and known or suspected allergy to egg and/or propofol


InterventionsIn group P (29 participants), anaesthesia was induced and maintained with propofol. In group H (26 participants), anaesthesia was induced and maintained with halothane 2-4% + N2O 70%


OutcomesAll side effects and adverse reactions in the perioperative period were recorded (laryngeal spasm, haemodynamic changes/dysrhythmias)

The time taken for induction (from injection of bolus to tolerance of eye speculum)

The time to recovery (from stoppage of infusion to OAA/S score 5). All children were discharged to the care of the parents at an Observer Assessment of Alertness/Sedation Scale (OAA/S) score of 5 at each level and only if no evidence of obstruction or respiratory difficulty was present

The episodes of restlessness, incessant crying or nausea/vomiting


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "They were randomly allocated (using a random number table) to receive either TIVA with propofol (group P) or inhalational anaesthesia..."

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Recovery was assessed by the recovery room nurse (independent, blinded)."

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasHigh risk"... usage of a different recovery endpoint scale (OAA/S score, 5 at each level) could have accounted for slight variability in recovery times compared with that reported in the literature."

Picard 2000

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 50 children. Generation of allocation: "A random numbers table was used to assign children to receive either propofol (group P) or sevoflurane anaesthesia (group S)". Blinded assessment of treatment allocation: "All observations and measurements were recorded by an independent anaesthesiologist who was blinded to the anaesthetic given". Withdrawals: "..two children were excluded because of postoperative bleeding and two others because of missing data. Thus, data from 24 children receiving sevoflurane and 22 children receiving propofol were analysed". Follow up: until discharge from the recovery area


Participants46 patients. Sex: Group P (propofol) - 13 male and 9 female; Group S (sevoflurane) - 12 male and 12 female. Age (mean): Group P - 5.2 years and Group S - 6 years. Inclusion criteria: healthy children (ASA I or II) undergoing elective tonsillectomy. Exclusion criteria: children who were screaming before arrival in the operating room were excluded from the study


InterventionsIn group P, anaesthesia was induced with a bolus of propofol, and maintained with a propofol and N2O 60%. In group S, anaesthesia was induced and maintained with sevoflurane 7 vol% and 2–3 vol%, respectively + N20 60%


OutcomesThe time to extubation (from the end of anaesthesia to extubation)

Time spent in the recovery room

The incidence of adverse events such as nausea, vomiting, laryngospasm and bronchospasm were noted and scored as follow: 1=mild, 2=moderate, 3=severe

The assessment of postoperative agitation was made using a four-point scale: 1=calm; 2=not calm but could be easily calmed; 3=moderately agitated or restless; 4=combative, excited or disoriented. Grades 1 and 2 were considered non-problematic behaviour, and grades 3 and 4 were considered to indicate agitation


NotesAt the completion of surgery, the operative site was infiltrated with bupivacaine 0.25% for postoperative analgesia


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A random numbers table was used to assign children to receive either propofol (group P) or sevoflurane anaesthesia (group S)"

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All observations and measurements were recorded by an independent anaesthesiologist who was blinded to the anaesthetic given"

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Of the 50 patients enrolled in the study, two children were excluded because of postoperative bleeding and two others because of missing data. Thus, data from 24 children receiving sevoflurane and 22 children receiving propofol were analysed"

Comment: missing outcome data balanced in numbers across intervention groups,with similar reasons for missing data across groups

Selective reporting (reporting bias)Low riskComment: the study appears to be free of reporting bias

Other biasLow riskComment: the study appears to be free of other sources of bias

Reimer 1993

MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: 75 children
Generation of allocation: "Patients were assigned to receive one of three anaesthetic regimens...". Allocation concealment: not reported. Blinded assessment of treatment allocation: "In the recovery room, recovery and emesis were observed by trained, recovery room nursing staff who were blinded to the group assignment". Withdrawals:discharge was delayed for surgical reasons in one patient in the P/N20 group. Recovery data relating to times of discharge and emesis data after discharge in this patient were excluded from analysis. Follow up: the incidence of emesis were observed in the recovery room and after discharge from hospital was recorded by telephone interview for the following intervals; during transport home, during the first 12 hr after discharge, and during the second 12 hours after discharge


Participants75 patients. Sex: Group Thio\Halothane - 7 male and 18 female; Group Propofol\O2 - 11 male and 14 female; Group Propofol\N2O - 9 male and 16 female. Age (mean): Group Thio\Halothane - 6.2years and Group Propofol\O2 - 6.3 years; Group Propofol\N2O - 5.1years. Inclusion criteria: healthy children, ASA physical status I or II, aged 2-12 years, scheduled for elective outpatient, strabismus surgery. Exclusion criteria: patients were excluded if they had an allergy to any of the drugs to be used or they had a symptomatic medical illness


InterventionsGroup(T\H): thiopentone followed by halothane 0.5-1.5% and nitrous oxide 70%/oxygen for maintenance
Group (P\O2): propofol
Group (P\N2O): propofol and nitrous oxide


OutcomesThe incidence of emesis (Involuntary retching was scored as emesis but nausea was not evaluated):

after discharge from hospital was recorded by telephone interview for the following intervals:during transport to home, during the first 12 hours after discharge, and during the second 12 hours after discharge. Overall emesis was defined as the total incidence of emesis at any of the study intervals

The length of stay in the PACU and the day care unit (DCU) were recorded

The time from arrival in the postanaesthetic recovery room (PACU) until a score of six was recorded as the recovery time (the Steward 6 recovery score)

The time to extubation was measured from the time of discontinuation of anaesthetic agents to the time of tracheal extubation


NotesAll patients were observed for two hours after discontinuation of the anaesthetic by recovery room nursing staff


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: " Patients were assigned to receive one of three anaesthetic regimens..."

Comment: insufficient information about the sequence generation

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
Low riskQuote: "Parents and the patient were not informed of the anaesthetic technique until the conclusion of the telephone interview."

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "In the recovery room, recovery and emesis were observed by trained, recovery room nursing staff who were blinded to the group assignment."

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Discharge was delayed for surgical reasons in one patient in the P/N20 group. Recovery data relating to times of discharge and emesis data after discharge in this patient were excluded from analysis."

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasLow riskComment: the study appears to be free of other sources of bias

Viitanen 1999

MethodsDesign: RCT. Two centres: the Helsinki University Central Hospital and the Central Hospital of Seiniijoki. Period: not reported. Sample size: 52 children. Generation of allocation: "Each child was randomly assigned, by computer-based random numbers listing, to receive intravenous induction with propofol (propofol group) or inhalational induction with sevoflurane 8% (inspired concentration) via a face mask (sevoflurane group)". Blinded assessment of treatment allocation: Intubation was performed and assessed by an anaesthesiologist blinded to the method of induction. Recovery was assessed by a trained nurse who was unaware of the induction method. Withdrawals: "All the questionnaires except for two from the propofol group were returned". Follow up: in the recovery room were recorded The Pain\Disconfort Scale to evaluate the quality of emergence from anaesthesia. In addition, the time to achieve discharge criteria were recorded. A postoperative questionnaire was given to the parents who were asked to record the well-being (pain, nausea, tiredness, drinking ability, sleep) of the child at home until 24hr after surgery


Participants52 patients. Age (mean): Group Propofol - 27 months and Group Sevoflurane - 24 months. Inclusion criteria: children, ASA physical status I or II, aged 1-3 years, presenting for ambulatory adenoidectomy with or without myringotomy. Exclusion criteria: patients were excluded if they had an allergy to any of the drugs to be used or they had a symptomatic medical illness


InterventionsGroup Propofol: intravenous induction with propofol

Group Sevoflurane: inhalational induction with sevoflurane 8% (inspired concentration) via a face mask

In both groups anaesthesia was continued with sevoflurane in nitrous oxide 70% in oxygen


OutcomesThe incidence of nausea and\or vomiting:

  • Recovery room
  • Home (until 24hr after surgery)


The haemodynamic responses to induction and intubation:

Bradycardia

Hypontension

Time to extubation was defined as the time from discontinuation of sevoflurane and nitrous oxide to recovery of spontaneous breathing and removal of the tracheal tube

The Pain/Discomfort scale according to Hannallah 1987 is was used to evaluate the quality of emergence from anaesthesia. If the total score on the Pain/Discomfort scale at any evaluation point exceeded the sum of three, emergence was regarded as delirious

Time to recovery: time from discontinuation of sevoflurane to achieve discharge criteria

The incidence of laryngospasm in the recovery room


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Each child was randomly assigned, by computer-based random numbers listing, to receive ..."

Allocation concealment (selection bias)Unclear riskComment: no information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Recovery was assessed by a speciaUy trained nurse who was unaware of the induction method."

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "All the questionnaires except for two from the propofol group were returned."

Selective reporting (reporting bias)Low riskComment: the study appears to be free of the reporting bias

Other biasLow riskComment: the study appears to be free of other sources of bias

Viitanen 1998

MethodsDesign: RCT. Single centre. Period: not reported. Sample size: 93 children
Generation of allocation: Each child was allocated randomly to one of three groups using a computer-generated random number table. Blinded assessment of treatment allocation: "In the recovery room, the recovery and behaviour of the children were assessed by the same nurse, who was unaware of the induction method used". Withdrawals: none. Follow up: in the recovery room were recorded sedation, crying, restlessness (motor activity) and agitation using an open scale scoring from 1-9. Scores were recorded at 10 minute intervals for the first hour and then every 30 minutes until discharge. In addition, the time to achieve discharge criteria from the recovery room were recorded. A postoperative questionnaire was given to the parents who were asked to record the well-being (pain, nausea, tiredness, drinking ability, sleep) and the behaviour of the child at home until 24hr after discharge


Participants93 patients. The three groups were comparable in age, weight, duration of anaesthesia and surgery. Inclusion criteria: children, ASA physical status I or II, aged 1-3 years, presenting for ambulatory adenoidectomy. Exclusion criteria: not reported


InterventionsGroup TH (31 participants) received thiopental 5mg\kg, group PAH (31 participants) received propofol and alfentanil and Group HH (31 participants) 5% inspired halothane for induction of anaesthesia.In all groups, anaesthesia was maintained with 1-3% halothane and 70% nitrous oxide delivered in oxygen


OutcomesSedation, crying, restlessness (motor activity) and agitation were evaluated using an open scale scoring from 1-9 (best to worst). If the child at any point of evaluation scored six or more for crying, restlessness or agitation, recovery from anaesthesia was considered delirious

Time (from discontinuation of halothane ) taken to achieve the criteria for discharge from the recovery room was recorded

The incidence of vomiting in the recovery room


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Each child was allocated randomly to one of three groups using a computer-generated random number table ..."

Allocation concealment (selection bias)Unclear riskComment: no information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "In the recovery room, the recovery and behaviour of the children were assessed by the same nurse, who was unaware of the induction method used."

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)High riskQuote: "A postoperative questionnaire was given to the parents who were asked to record the well-being (pain,nausea, tiredness, drinking ability, sleep) and the behaviour of the child at home until 24hr after discharge."

"At home, the well-being and recovery of the children were similar in all groups."

Comment: However, the data of these endpoints were not shown in the study

Other biasLow riskComment: the study appears to be free of other sources of bias

Weir 1993

MethodsDesign: RCT. Single centre. Period: not reported. Sample size: 78children
Generation of allocation: "Patients were assigned randomly to one of two groups". Allocation concealment: not reported. Blinded assessment of treatment allocation: "The incidence of nausea, retching,or vomiting was recorded by a blinded observer". Withdrawals: none. Follow up: in the recovery room were recorded the incidence of nausea, retching, or vomiting. The family was contacted after 24 hours by telephone to determine the incidence of nausea and\or vomiting at home


Participants78 patients. Sex: Group A (Halothane) - 14 male and 25 female; Group B (Propofol) - 19 male and 20 female. Age (mean): Group A - 5.4 years and Group B - 5.4 years. Inclusion criteria: children, ASA class I or II, aged between 3 and 12 years and undergoing strabismus surgery as outpatients. Exclusion criteria: not reported


InterventionsThe anaesthesia was induced in all patients by inhalation of nitrous oxide, oxygen, and halothane via a mask. In group A (halothane), anaesthesia was maintained using halothane. The group B (propofol) received propofol; both groups received 66% nitrous oxide in oxygen throughout surgery


OutcomesThe incidences of both nausea and vomiting and vomiting alone occurring in the first 24 hours postoperatively

Time to discharge


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Patients were assigned randomly to one of two groups"

Comment: I do not know if it was done

Allocation concealment (selection bias)High riskComment: probably not done

Blinding of participants and personnel (performance bias)
All outcomes
High riskComment: probably not done

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...the incidence of nausea, retching,or vomiting was recorded by a blinded observer"

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: no missing outcome data

Selective reporting (reporting bias)High riskQuote: "Patient readiness for discharge was assessed by standard criteria; namely the patient being alert and oriented, at least 1.5 hours after tracheal extubation, and more than 1 hour after the administration of opioid analgesia"

Comment: the time to discharge was poorly defined

Other biasLow riskComment: the study appears to be free of other sources of bias

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Cheng 1998The study was classified as high risk of bias for randomization and blinding

Davis 1991Compared the maintenance of anaesthesia with and without opioid (halothane and N2O versus halothane and N2O and alfentanil)

Davis 1997All children in the study were premedicated with midazolam. The use of premedication can change the following outcome: time to emergence, the incidence of nausea or vomiting or both and the incidence of agitation

Elliott 2002The study compared inhalation anaesthesia (induction and maintenance with sevoflurane) versus balanced anaesthesia (induction with propofol and maintenance with halothane). However, the inhalational agents were different and this complicates the analysis of data

Elliott 2003The study compared inhalation anaesthesia (induction and maintenance with sevoflurane) versus balanced anaesthesia (induction with propofol and maintenance with halothane). However, the inhalational agents were different and this complicates the analysis of data

Konig 2009Patients received antiemetic: dexamethasone

Kotiniemi 1996All children in the study were premedicated with diazepam and meperidine. The use of premedication can change the following outcome: time to emergence, the incidence of nausea and vomiting and the incidence of agitation

Kubo 2001Some children in the study were premedicated with midazolam. The use of premedication can change the following outcome: time to emergence, the incidence of nausea and vomiting and the incidence of agitation

Laiq 2008The study compared inhalation anaesthesia (induction and maintenance with sevoflurane + N2O) versus balanced anaesthesia (induction with propofol and maintenance with halothane + N2O). However, the inhalational agents were different and this complicates the analysis of data

Martin 1993All children in the study were premedicated with diazepam and meperidine. The use of premedication can change the following outcome: time to emergence, the incidence of nausea and vomiting and the incidence of agitation

Moore 1994The outcomes were not relevant: time from end of surgery to eye opening; time from end of surgery to responding to commands; quality of anaesthesia (good, fair or poor)

Moore 2003The study compared inhalation anaesthesia (induction and maintenance with sevoflurane) versus balanced anaesthesia (induction with propofol and maintenance with halothane). However, the inhalational agents were different and this complicates the analysis of data

Oh 2010The study compared the maintenance of sevoflurane anaesthesia with or without opioid

Ozer 2001The children in the study were premedicated with midazolam. The use of premedication can change the following outcome: time to emergence, the incidence of nausea and vomiting and the incidence of agitation

Tsai 2008The children in the study were premedicated with midazolam. The use of premedication can change the following outcome: time to emergence, the incidence of nausea and vomiting and the incidence of agitation

Ved 1996Some patients received antiemetic (dexamethasone)

Watcha 1991Some patients received antiemetic (droperidol)

Woodward 1997The procedures were not ambulatory

Yelken 2004The children in the study were premedicated with midazolam

 
Characteristics of studies awaiting assessment [ordered by study ID]
Gouda 2002

MethodsThere is no data in the abstract (not yet assessed)

ParticipantsPreschool children undergoing day case surgery

InterventionsSevoflurane anaesthesia versus total intravenous anaesthesia with propofol

OutcomesNot known

Notes

Moussa 1995

MethodsNot known

ParticipantsNot known

InterventionsAnaesthesia with propofol versus thiopentone with isoflurane and nitrous oxide

OutcomesTime to recovery and quality of recovery

Notes

 
Comparison 1. Induction and maintenance: sevoflurane + nitrous oxide (N2O) versus propofol + N2O

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Nausea and vomiting4176Odds Ratio (M-H, Fixed, 95% CI)2.96 [1.35, 6.49]

 2 Postoperative behavioural disturbances4176Odds Ratio (M-H, Fixed, 95% CI)2.67 [1.14, 6.23]

 3 intraoperative and postoperative respiratory and cardiovascular complications3130Odds Ratio (M-H, Fixed, 95% CI)0.75 [0.27, 2.13]

 4 Time to discharge recovery (min)3136Mean Difference (IV, Fixed, 95% CI)3.61 [0.32, 6.90]

 5 Time to discharge from hospital (min)283Mean Difference (IV, Random, 95% CI)19.54 [-10.51, 49.59]

 
Comparison 2. Maintenance: inhalational versus intravenous

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Nausea and vomiting4Odds Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 Thiopentone\Halothane+N2O vs Propofol\Propofol+N2O
4176Odds Ratio (M-H, Fixed, 95% CI)3.23 [1.49, 7.02]

    1.2 Thiopentone\Halothane+N2O vs Propofol\Propofol
287Odds Ratio (M-H, Fixed, 95% CI)7.44 [2.60, 21.26]

 2 Time to discharge from recovery (min)3Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Thiopentone\Halothane + N2O vsPropofol\Propofol + N2O
3125Mean Difference (IV, Random, 95% CI)11.07 [-3.83, 25.97]

    2.2 Thiopentone\Halothane +N2O vs Propofol\Propofol
287Mean Difference (IV, Random, 95% CI)-1.61 [-10.37, 7.16]

 
Summary of findings for the main comparison. Induction and maintenance: sevoflurane + nitrous oxide (N2O) compared to propofol + N2O for paediatric outpatient surgery

Induction and maintenance: sevoflurane + nitrous oxide (N2O) compared to propofol + N2O for paediatric outpatient surgery

Patient or population: paediatric
Settings: outpatient surgery
Intervention: sevoflurane + N2O
Comparison: propofol + N2O

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Propofol + N2OSevoflurane + N2O

Postoperative nausea and vomiting
Follow-up: until 24 hours1
Study populationOR 2.96
(1.35 to 6.49)
176
(4 studies)
⊕⊕⊝⊝
low2,3

161 per 1000362 per 1000
(206 to 554)

Postoperative behavioural disturbances
Different scales
Follow-up: until discharge from recovery room4
Study populationOR 2.67
(1.14 to 6.23)
176
(4 studies)
⊕⊝⊝⊝
very low2,3,5

115 per 1000257 per 1000
(129 to 447)

Intraoperative and postoperative respiratory and cardiovascular complications
Follow-up: until discharge from hospital (hours)
Study populationOR 0.75
(0.27 to 2.13)
130
(3 studies)
⊕⊝⊝⊝
very low6,7,8

246 per 1000197 per 1000
(81 to 410)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1One study (Picard 2000) evaluated the risk of postoperative nausea and vomiting until discharge from recovery room and three (Baykara 1998; Guard 1998; Gurkan 1999) until 24 hours of postoperative.
2 Three studies (Guard 1998; Gurkan 1999; Picard 2000) were classified as high risk of bias for allocation concealment and one study (Baykara 1998) was classified as unclear risk of bias for randomization and high for blinding of outcome assessment.
3 The studies were conducted with different types of surgeries and duration of anaesthesia.
4 Three studies reported the risk of postoperative behavioural disturbances until discharge recovery (Baykara 1998; Gurkan 1999; Picard 2000) and one (Guard 1998) reported during emergence of anaesthesia.
5 Three studies (Baykara 1998; Guard 1998; Gurkan 1999) did not describe the postoperative behavioural disturbances criteria.
6 One study (Baykara 1998) was classified as unclear risk of bias for randomization and high for blinding of outcome assessment and the other studies (Guard 1998; Gurkan 1999) were classified as high risk of bias for allocation concealment.
7 Two studies (Baykara 1998; Guard 1998) reported respiratory complication (laryngospasm) in the recovery room and another study (Gurkan 1999) reported cardiac complication (bradycardia ) during the induction of anaesthesia. The meta-analysis of the studies showed significant heterogeneity (49%),probably because the complications were not equal and they were analysed in different periods with different surgical procedure.
8The results are imprecise because the analysis of studies of respiratory complications were based on few patients(90 children) and few events(three).
 
Summary of findings 2. Maintenance anaesthesia: inhalational compared to intravenous for paediatric outpatient surgery

Maintenance anaesthesia: inhalational compared to intravenous for paediatric outpatient surgery

Patient or population: paediatric
Settings: outpatient surgery
Intervention: inhalational
Comparison: intravenous

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

IntravenousMaintenance: inhalational

Nausea and vomiting - subgroup analysis: thiopentone or halothane + N2O versus propofol or propofol + N2O
Follow-up: 24 hours after surgery1
Study populationOR 3.23
(1.49 to 7.02)
176
(4 studies)
⊕⊕⊝⊝
low2

310 per 1000592 per 1000
(401 to 760)

Nausea and vomiting - subgroup analysis: thiopentone or halothane + N2O versus propofol or propofol + N2O
Follow-up: 24 hours after surgery
Study populationOR 7.44
(2.6 to 21.26)
87
(2 studies)
⊕⊕⊝⊝
low3,4

349 per 1000799 per 1000
(582 to 919)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Three studies (Crawford 1998; Hannallah 1994; Reimer 1993) reported these outcome in the recovery and 24hs after surgery and only one study (Borgeat 1990) reported these until discharge from recovery.
2 In three studies (Borgeat 1990; Hannallah 1994; Reimer 1993) the method of randomization was unclear and they were classified as high risk of bias for the allocation concealment.Besides,the studies were in different ambulatory surgeries with duration varying from 36 to 75 minutes.
3 Two studies (Crawford 1998; Reimer 1993) were classified as high risk of bias for the allocation concealment and in Reimer 1993 the method of randomization was unclear.
4The results are imprecise because the analysis of studies of the risk of PONV were based on few patients (87 children).