This study aimed to establish which anesthetic agents are associated with minimized adverse outcomes during laryngeal mask airway (LMA) insertion. Databases were searched for randomized controlled trials (RCTs) with American Society of Anesthesiologists I or II adult patients (≥15 years of age) receiving general anesthesia (GA) with an LMA. Propofol only was the comparator to other anesthetics used during LMA insertion. The primary outcome was prolonged apnea, and secondary outcomes were adverse airway events, LMA insertion failure, inadequate depth of anesthesia, and hemodynamic events. A network meta-analysis was conducted to estimate the treatment effects (odds ratios, 95% credible intervals, and surface under the cumulative ranking curve [SUCRA]). A total of 28 anesthetic combinations used on 4695 patients for GA induction and LMA insertion were examined across 53 RCTs. Overall, there was an apnea incidence rate of 33.3% (849 of 2548) with a mean time of 3.74 ± 3.56 minutes (n = 3091). Propofol + dexmedetomidine had the highest overall summed score of SUCRA ranks in reducing adverse outcomes (apnea incidence: SUCRA = 37%, apnea time: SUCRA = 66%, airway adverse event: SUCRA = 67%, insertion failure: SUCRA = 73%, inadequate depth of anesthesia: SUCRA = 84%). In comparison among all propofol combinations, propofol alone ranked lowest for overall summed score of SUCRA in reducing adverse outcomes (apnea incidence: SUCRA = 47%, apnea time: SUCRA = 71%, airway adverse event: SUCRA = 9%, insertion failure: SUCRA = 20%, inadequate depth of anesthesia: SUCRA = 9%). All anesthetic combinations, other than those with thiopental, reduced adverse outcomes as compared with propofol alone. The combination of propofol and dexmedetomidine infused over 10 minutes ranked as the most effective for reducing adverse outcomes during LMA insertion.Objective
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Preferred Reporting Items for Systematic Reviews and Meta-Analyses Flow Diagram
Flow diagram of study inclusion and exclusions. LMA indicates laryngeal mask airway; ASA, American Society of Anesthesiologists; and RCT, randomized controlled trial.
Network Geometries of the Adverse Outcomes
The network geometry of the primary, (A) apnea incidence and (B) apnea time, and secondary, (C) airway adverse events, (D) insertion failure, and (E) inadequate depth of anesthesia, outcomes during LMA placement. Gray connecting lines between circles indicate the direct comparison of interventions and the circle width is proportional to the number of studies evaluating the comparison. The circle volume is proportional to the number of patients who received the intervention. PPF indicates propofol; MDZ, midazolam; AA, agonist-antagonist; IV, intravenous; NMBA, neuromuscular blocking agent; and THIO, thiopentone.
NMA Outcome SUCRA Values and ORs
SUCRA values and forest plots of odds ratios and mean differences of NMA of (A) apnea time, (B) apnea incidence, (C) airway adverse event, (D) insertion failure, and (E) inadequate depth of anesthesia. NMA indicates network meta-analysis; SUCRA, surface under the cumulative ranking curve; OR, odds ratio; CrI, credible interval; PPF, propofol; MDZ, midazolam; AA, agonist-antagonist; IV, intravenous; NMBA, neuromuscular blocking agent; THIO, thiopentone; Lido., lidocaine; and Top., topical.
Cumulative SUCRA Scores of Anesthetic Interventions
Summed scores of anesthetic intervention SUCRA ranks for apnea (red), airway adverse event (blue), insertion failure (yellow), and inadequate depth of anesthesia (green). SUCRA indicates surface under the cumulative ranking curve; PPF, propofol; MDZ, midazolam; NMBA, neuromuscular blocking agent; AA, agonist-antagonist; and IV, intravenous.
Risk of Bias Assessment
Each included study assessed by review authors’ judgments for risk of bias and deemed as low risk of bias (+, green), unclear risk of bias (?, yellow), or high risk of bias (−, red).
Contributor Notes