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

Zhang 2015.

Methods RCT, parallel design, single‐centre
Participants Total number of randomized participants: 80
Inclusion criteria

  1. Senile gastric cancer patients receiving selective radical surgery


Exclusion criteria

  1. Mental health disorder

  2. Severe dysfunction of heart, lung, liver, or kidney

  3. Spinal deformity

  4. Contraindications of epidural anaesthesia

  5. History of severe trauma

  6. Surgical treatment


Type of surgery: radical surgery for gastric cancer
Baseline characteristics
TIVA group (without epidural)

  1. Age, mean (SD): 71.4 (± 5.6) years

  2. Gender, M/F: 15/5

  3. ASA grade: ASA I: 4; ASA II: 16


Inhalational maintenance group (without epidural)

  1. Age, mean (SD): 67.9 (± 7.2) years

  2. Gender, M/F: 16/4

  3. ASA grade: ASA I: 5; ASA II: 15


TIVA group (with epidural)

  1. Age, mean (SD): 69.0 (± 6.6) years

  2. Gender, M/F: 15/5

  3. ASA grade: ASA I: 3; ASA II: 17


Inhalational maintenance group (with epidural)

  1. Age, mean (SD): 70.4 (± 5.9) years

  2. Gender, M/F: 14/6

  3. ASA grade: ASA I: 4; ASA II: 16


Country: China
Setting: hospital
Interventions TIVA group (without epidural)
Participants: n = 20; 0 losses
Induction details: TCI propofol 4.0 µg/mL, 3 µg/kg to 4 µg/kg fentanyl and 0.2 mg/kg cisatracurium IV
Maintenance details: fentanyl IV 0.15 µg/kg/min to 0.35 µg/kg/min, TCI propofol 1.5 µg/mL to 3.0 µg/mL. To maintain BIS 40 to 60
Other information: 30 minutes before end of surgery, 0.6 µg to µg 1 µg fentanyl IV
Inhalational maintenance group (without epidural)
Participants: n = 20; 0 losses
Induction details: 8% sevoflurane at high‐flow rate, 8 L/min to 10 L/min. After loss of consciousness, adjusted to 2 L/min to achieve end‐tidal concentration of 2%
Maintenance details: continuous inhalation end‐tidal concentration of 1.5% to 3.5%. Cisastracurium 0.05 mg/kg to 0.1 mg/kg. To maintain BIS 40 to 60
Other info: 30 minutes before end of surgery, 0.6 µg to 1 µg fentanyl IV
TIVA group (with epidural)
Participants: n = 20; 0 losses
Induction details: TCI propofol 4.0 µg/mL, 3 µg/kg to 4 µg/kg fentanyl and 0.2 mg/kg cisatracurium IV
Maintenance details: fentanyl IV 0.15 µg/kg/min to 0.35 µg/kg/min, TCI propofol 1.5 µg/mL to 3.0 µg/mL. 30 minutes before skin incision: 10 mL ropivacaine and 2 µg/mL, fentanyl injected into epidural space
Other info: once epidural puncture was performed, a test dose of 3 mL 2% lidocaine to confirm level and absence of adverse reactions. 30 minutes before end of surgery, 10 mL mixed anaesthesia solution
Inhalational maintenance group (with epidural)
Participants: n = 20; 0 losses
Induction details: 8% sevoflurane at high‐flow rate, 8 L/min to 10 L/min. After loss of consciousness, adjusted to 2 L/min. to achieve end‐tidal concentration of 2%
Maintenance details: 30 minutes before skin incision: 10 mL ropivacaine and 2 µg/mL fentanyl injected into epidural space. Continuous inhalation end‐tidal concentration of 1.5% to 3.5% sevoflurane. Cisastracurium 0.05 mg/kg to 0.1 mg/kg. BIS 40 to 60
Other info: once epidural puncture was performed, a test dose of 3 mL 2% lidocaine to confirm level and absence of adverse reactions. 30 minutes before end of surgery, 10 mL mixed anaesthesia solution
Outcomes

  1. Dose of remifentanil

  2. Incidence of hypotension (defined as SBP ≤ 90 mmHg or reduction ≥ 20% or baseline for ≥ 5 minutes)

  3. Time to awakening

  4. Time to endotracheal tube removal

  5. Time to orientation

  6. Time to achieve modified Aldrete scores ≥ 9

  7. Emergence agitation
Notes Funding/declarations of interest: not reported
Study dates: not reported
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Use of a random number table
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 No apparent loss of study participants
Selective reporting (reporting bias) Unclear risk Study authors do not report clinical trials registration. Not feasible to judge risk of selective outcome reporting
Other bias Low risk No other sources of bias identified

AAA: abdominal aortic aneurysm
 aMCI: amnesic mild cognitive impairment
 ApoE: apoliproprotein E
 ASA: American Society of Anesthesiologists
 BDI: Beck Depression Inventory
 BIS: bispectral index
 BMI: body mass index
 BP: blood pressure
 CAM: confusion assessment method
 DRS: delirium rating scale
 DSST: Digit Symbol Substitution Test
 FiO2: fraction of inspired oxygen
 GA: general anaesthesia
 HR: heart rate
 ICU: intensive care unit
 im: intramuscular
 IV: intravenous(ly)
 IQR: interquartile range
 ITT: intention to treat
 LMA: laryngeal mask airway
 MAC: minimum alveolar concentration
 MAP: mean arterial pressure
 MCI: mild cognitive impairment
 M/F: male/female
 MI: myocardial infarction
 MMSE: Mini‐Mental State Examination
 MMT: Mini Mental Test
 n: number of randomized participants per group
 N2O: nitrous oxide
 NYHA: New York Heart Association
 O2: oxygen
 PACU: postanaesthesia care unit
 PCA: patient controlled analgesia
 PCI: percutaneous coronary intervention
 POCD: postoperative cognitive dysfunction
 PONV: postoperative nausea and vomiting
 PP: per protocol
 PSI: patient state index
 RAVLT: Rey Auditory Verbal Learning test
 RCT: randomized control trial
 SBP: systolic blood pressure
 SD: standard deviation
 SOFA: Sequential Organ Failure Assessment
 T8‐T10: epidural given between the 8th and 9th, or the 9th and 10th thoracic vertebrae
 TCI: target‐controlled infusion
 TDT: Trieger Dot Test
 TEE: transoesophageal echocardiography
 TIVA: total intravenous anaesthesia
 TKA: total knee arthroplasty
 VAS: visual analogue scale
 VIMA: volatile induction and maintenance anaesthesia
 vs: versus