Volatile sedation in the intensive care unit: A systematic review and meta-analysis

Ha Yeon Kim, Ja Eun Lee, Ha Yan Kim, Jeongmin Kim, Ha Yeon Kim, Ja Eun Lee, Ha Yan Kim, Jeongmin Kim

Abstract

Background: Volatile sedation in the intensive care unit (ICU) may reduce the number of adverse events and improve patient outcomes compared with intravenous (IV) sedation. We performed a systematic review and meta-analysis comparing the effects of volatile and IV sedation in adult ICU patients.

Methods: We searched the PubMed, Embase, Cochrane Central Register, and Web of Science databases for all randomized trials comparing volatile sedation using an anesthetic-conserving device (ACD) with IV sedation in terms of awakening and extubation times, lengths of ICU and hospital stay, and pharmacologic end-organ effects.

Results: Thirteen trials with a total of 1027 patients were included. Volatile sedation (sevoflurane or isoflurane) administered through an ACD shortened the awakening time [mean difference (MD), -80.0 minutes; 95% confidence intervals (95% CIs), -134.5 to -25.6; P = .004] and extubation time (MD, -196.0 minutes; 95% CIs, -305.2 to -86.8; P < .001) compared with IV sedation (midazolam or propofol). No differences in the lengths of ICU and hospital stay were noted between the 2 groups. In the analysis of cardiac effects of sedation from 5 studies, patients who received volatile sedation showed lower serum troponin levels 6 hours after ICU admission than patients who received IV sedation (P < .05). The effect size of troponin was largest between 12 and 24 hours after ICU admission (MD, -0.27 μg/L; 95% CIs, -0.44 to -0.09; P = .003).

Conclusion: Compared with IV sedation, volatile sedation administered through an ACD in the ICU shortened the awakening and extubation times. Considering the difference in serum troponin levels between both arms, volatile anesthetics might have a myocardial protective effect after cardiac surgery even at a subanesthetic dose. Because the included studies used small sample sizes with high heterogeneity, further large, high-quality prospective clinical trials are needed to confirm our findings.

Conflict of interest statement

No external funding and no competing interests were declared by the authors.

Figures

Figure 1
Figure 1
Flow diagram depicting the study selection process.
Figure 2
Figure 2
Risk of bias graph (A) and summary (B) of the included studies. + indicates a low risk of bias, − indicates a high risk of bias, and? indicates an unclear risk of bias.
Figure 3
Figure 3
Forest plot of the mean differences and 95% confidence intervals (CIs) for awakening time (in min) in the volatile and IV sedation groups. Data were analyzed using a random effects model.
Figure 4
Figure 4
Forest plot of the mean differences and 95% confidence intervals (CIs) for extubation time (in min) in the volatile and IV sedation groups. Data were analyzed using a random effects model.
Figure 5
Figure 5
Forest plot of the mean differences and 95% confidence intervals (CIs) for length of stay (in h) in the intensive care unit in the volatile and IV sedation groups. Data were analyzed using a fixed effects model.
Figure 6
Figure 6
Forest plot of the mean differences and 95% confidence intervals (CIs) for length of stay (in d) in the hospital in the volatile and IV sedation groups. Data were analyzed using a fixed effects model.
Figure 7
Figure 7
Forest plot of the mean differences and 95% confidence intervals (CIs) for serum troponin levels (μg/L) at different time points after ICU admission. The data were analyzed by dividing them into time intervals as follows: (A) 0–6 h, (B) 6–12 h, (C) 12–24 h, and (D) 24–48 h after ICU admission. (E) The line represents the difference in means and the vertical bar represents 95% confidence intervals for serum troponin levels (vertical axis) at different time points after ICU admission (horizontal axis).
Figure 8
Figure 8
Forest plot of the mean differences and 95% confidence intervals (CIs) for serum N-terminal prohormone of brain natriuretic peptide levels (pg/mL) on the first postoperative day. Data were analyzed using a fixed effects model.
Figure 9
Figure 9
Forest plot of the mean differences and 95% confidence intervals (CIs) for serum creatinine levels (mg/dL) on the first postoperative day. Data were analyzed using a fixed effects model.
Figure 10
Figure 10
Forest plot of the risk ratio and 95% confidence intervals (CIs) for the incidence of delirium in the volatile and IV sedation groups. Data were analyzed using a fixed effects model.
Figure 11
Figure 11
Forest plot of the risk ratio and 95% confidence intervals (CIs) for the incidence of postoperative nausea and vomiting in the volatile and IV sedation groups. Data were analyzed using a fixed effects model.

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