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This meta-analysis is from Rochester, New York, and aims to add more evidence for the use of TIVA in endoscopic sinus surgery (FESS) to arm rhinologists keen for a quick, bloodless FESS in the discussion with anaesthetists who prefer inhalation. The topic has been the subject of previous meta-analyses and numerous RCTs which have given a mixed bag of results. Two Cochrane reviews in 2013 and 2016 found that TIVA improved the surgical field but made no difference to estimated blood loss or operating time. These reviews excluded many existing RCTs due to their strict inclusion criteria. This study included all English language RCTs where TIVA with a short acting opiate was compared to inhalation volatile anaesthesia with the same short acting opiate, regardless of age or publication date. A few RCTs published since the Cochrane review were also included. Primary outcomes studied were surgical field quality and estimated blood loss, with secondary outcomes of operative time, anaesthetic time, mean arterial pressure (MAP) and heart rate. Demographics and study characteristics were also extracted. Twelve papers satisfied the inclusion and exclusion criteria for analysis. This amounted to 560 patients, with an average age of 32-51 years and Lund-Mackay score of 6-7. Most studies used either fentanyl or remifentanil as the short acting opioid. One study used alfentanil. For inhalation, half the studies used sevoflurane, whilst the other half used isoflurane or desflurane. Selection, performance and detection bias were difficult to ascertain since the details were not provided; some studies did not state whether the surgeon was blinded to the type of anaesthetic used.

In the pooled analysis of results, there was no difference between TIVA and inhalational anaesthesia in regard to anaesthetic time or heart rate. There were, however, statistically significant differences between the two methods with regards to surgical visibility, estimated blood loss, operative time and MAP.

A subgroup analysis indicated that the use of remifentanil as the short-acting opiate in combination with TIVA provided superior results across in regard to surgical field quality, estimated blood loss and operative time. They conclude that TIVA with propofol and remifentanil would be superior for FESS. 

Total intravenous anaesthesia versus inhaled anaesthesia for endoscopic sinus surgery: a meta-analysis of randomized controlled trials.
Kolia N, Man L.
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Suki Ahluwalia

Cairns Hospital / James Cook University, Queensland, Australia.

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