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Renal safety of critical care sedation with sevoflurane: a systematic review and meta-analysis

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Abstract

Volatile anesthetic agents are increasingly widely used for critical care sedation. There are concerns that sevoflurane presents a risk of renal injury when used in this role. RCTs comparing the use of critical care sevoflurane sedation with any control in humans were systematically identified using MEDLINE, Cochrane CENTRAL, web of Science, and CINAHL (until May 2022), if they presented comparative data on renal function or serum inorganic fluoride levels. Pooled SMDs (95% CI) were calculated where possible after assessment of quality with GRADE and risk of bias with ROB-2. Eight studies analyzing 793 patients were included. The median duration of use of critical care sevoflurane sedation was 4.8 [IQR 3.5–9.2] hours; however, most trials also included a period of prior intraoperative use. No significant difference was found in serum creatinine at 1 day (SMD 0.05, 95% CI − 0.12 to 0.21), 48 h (SMD = − 0.04; 95% Cl − 0.25 to 0.17), 72 h (SMD = − 0.15; 95% CI − 0.45 to 0.15), and at discharge (SMD = − 0.1; 95% CI − 0.3 to 0.13) between the sevoflurane group and the control groups. Creatinine clearance was measured in two studies at 48 h with no significant difference (SMD = − 0.13; 95% Cl − 0.38 to 0.11). Levels of serum inorganic fluoride were significantly elevated in patients where sevoflurane was used. Sevoflurane was not associated with renal failure when used for critical care sedation of fewer than 72-h duration, despite the elevation of serum fluoride. Longer-term studies are currently inadequate, including in patients with compromised renal function, to further evaluate the role of sevoflurane in this setting.

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All data supporting the findings of this study are available within the paper and its Supplementary Information.

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Acknowledgements

We are grateful to Dr. A. Bos, Professor M. Jabaudon, Professor A. Jerath and Dr. A. Meiser for their responses to our requests for additional data on their studies.

Funding

This study forms part of a funded Ph.D by one of the authors (Ben Taylor). This is supported by the Defence Medical Services Research Steering Group of the UK Ministry of Defence [Grant number 21/22.026].

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Authors and Affiliations

  1. Department of Anaesthesia and Critical Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK

    Ben Taylor & Timothy E. Scott

  2. Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK

    Ben Taylor, Timothy E. Scott & James Shaw

  3. Emergency Medical Retrieval and Transport Service Cymru, Llanelli, UK

    James Shaw

  4. Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK

    Ben Taylor, Timothy E. Scott & Nachiappan Chockalingam

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  1. Ben Taylor
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Contributions

BT, TS, and NC contributed to the study conception and design. BT, JS and TS conducted searches, screened abstracts, and screened potentially responsive articles in full text. BT and NC extracted data and analysis was conducted by BT and checked by NC. The first draft of the manuscript was completed by BT, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Ben Taylor.

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Taylor, B., Scott, T.E., Shaw, J. et al. Renal safety of critical care sedation with sevoflurane: a systematic review and meta-analysis. J Anesth 37, 794–805 (2023). https://doi.org/10.1007/s00540-023-03227-y

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