Does Anaesthesia With Nitrous Oxide Affect Mortality or Cardiovascular Morbidity? A Systematic Review With Meta-analysis and Trial Sequential Analysis

Background. The role of nitrous oxide in modern anaesthetic practice is contentious. One concern is that exposure to nitrous oxide may increase the risk of cardiovascular complications. ENIGMA II is a large randomized clinical trial currently underway which is investigating nitrous oxide and cardiovascular complications. Before the completion of this trial, we performed a systematic review and meta-analysis, using Cochrane methodology, on the outcomes that make up the composite primary outcome. Methods. We used conventional meta-analysis and trial sequential analysis (TSA). We reviewed 8282 abstracts and selected 138 that fulfilled our criteria for study type, population, and intervention. We attempted to contact the authors of all the selected publications to check for unpublished outcome data. Results. Thirteen trials had outcome data eligible for our outcomes. We assessed three of these trials as having a low riskof bias. Using conventional meta-analysis, the relative riskof short-term mortality in the nitrous oxide group was 1.38 [95% confidence interval (CI) 0.22–8.71] and the relative risk of long-term mortality in the nitrous oxide group was 0.94 (95% CI 0.80–1.10). In both cases, TSA demonstrated that the data were far too sparse to make any conclusions. There were insufficient data to perform meta-analysis for stroke, myocardial infarct, pulmonary embolus, or cardiac arrest.