Comparison of Anesthetics for Laryngeal Mask Airway Insertion: A Network Meta-Analysis.

Objective: This study aimed to establish which anesthetic agents are associated with minimized adverse outcomes during laryngeal mask airway (LMA) insertion. Methods: 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]). Results: 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%). Conclusion: 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.