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. 2018 Aug 21;2018(8):CD012317. doi: 10.1002/14651858.CD012317.pub2

Kim 2015a.

Methods RCT, parallel design, single‐centre
Participants Total number of randomized participants: 60
Inclusion criteria

  1. ASA I to II, > 65 years of age, scheduled for elective orthopaedic surgery


Exclusion criteria

  1. Severe heart disease (NYHA class > III)

  2. Severe arrhythmia

  3. Uncontrolled hypotension

  4. Haemodynamic instability

  5. Drug hypersensitivity

  6. Any cognitive deficiency, hepatic or renal compromise

  7. Infectious disease

  8. Surgery lasting > 3 hours


Type of surgery: orthopaedic surgery (hip replacement, knee replacement, long bone fracture fixation, spinal surgery)
Baseline characteristics
TIVA group

  1. Age, mean (SD): 73.5 (± 7.2) years

  2. Gender, M/F: 8/22

  3. ASA grade: ASA I: 11; ASA II: 19


Inhalational maintenance group

  1. Age, mean (SD): 72.3 (± 6.2) years

  2. Gender, M/F: 8/20

  3. ASA grade: ASA I: 8; ASA II: 20


Country: South Korea
Setting: hospital
Interventions TIVA group
Participants: n = 30; 0 losses
Induction details: premedication with midazolam 0.05 mg/kg im. Remifentanil and propofol based on Minto and Marsh pharmacokinetic model using TCI. Target effect‐site concentration 3 µg/mL propofol, 2.5 ng/mL remifentanil. Rocuronium 1.0 mg/kg
Maintenance details: propofol‐remifentanil with 50% O2 and 50% air mix. Target effect‐site concentration 3 µg/mL propofol, 2.5 ng/mL remifentanil. Rocuronium 1.0 mg/kg. To maintain BIS near 50 (range 40 to 60)
Other information: after surgery fentanyl administration using PCI
Inhalational maintenance group
Participants: n = 30; 2 losses (owing to surgery lasting more than 2 hours); 27 analysed
Induction details: premedication with midazolam 0.05 mg/kg im. Propofol 1.5 mg/kg to 2.0 mg/kg, 3% to 4 % sevoflurane and 50% O2‐ air mixture. Rocuronium 1.0 mg/kg
Maintenance details: sevoflurane with 50% O2 and 50% air mix. Adjusted to maintain BIS near 50 (range 40 to 60)
Other information: fentanyl after surgery same as TIVA group
Outcomes

  1. Pain score

  2. PONV

  3. Duration of time in recovery
Notes Funding/declarations of interest: grants from Chosun University Medical Research Institute. Study authors declare no competing interests
Study dates: not reported
Note: study has four comparison groups ‐ sevoflurane vs TIVA, with and without dexmedetomidine. For the review, we have only used the comparison groups without dexmedetomidine
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Use of computer‐generated randomization
Allocation concealment (selection bias) Unclear risk No details
Blinding of participants and personnel (performance bias) 
 All outcomes High risk Not feasible to blind anaesthetists to intervention groups
Blinding of outcome assessment (detection bias) 
 All outcomes Unclear risk No details
Incomplete outcome data (attrition bias) 
 All outcomes Low risk Loss of 2 participants in the inhalation group; few losses unlikely to influence outcome data
Selective reporting (reporting bias) Low risk Prospective trial registration (NCT01851005). Most outcomes were reported, although we noted that adverse events (secondary outcomes) were not included in the written report. For the purpose of our review, MAP was reported but not in terms of hypotension.
Other bias Unclear risk Differences between groups in use of remifentanil and fentanyl. Also, a higher ratio of female to male participants; however, this is balanced between groups