Efficacy of premedication with intranasal dexmedetomidine on inhalational induction and postoperative emergence agitation in pediatric undergoing cataract surgery with sevoflurane

Effect of video-based interventions on emergence delirium in pediatric patients: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Emergence delirium is frequently observed in pediatric patients. With advancements in video-based interventions, such as cartoons, video games, and virtual reality, these modalities may contribute to a reduced incidence of emergency delirium among children. However, robust evidence supporting their efficacy remains necessary.

METHODS

The authors conducted a systematic search across multiple databases, including Embase, MEDLINE, and Cochrane Library, to identify all randomized controlled trials comparing video-based interventions with control treatments in pediatric emergence delirium. Data were aggregated and analyzed using Review Manager 5.4 to evaluate the effectiveness of video-based interventions.

RESULTS

The analysis included eight randomized controlled trials comprising 872 children. The intervention group showed a trend toward lower Pediatric Anesthesia Emergence Delirium scores (p = 0.10) and fewer emergence delirium events (p = 0.52). Seven studies demonstrated that video-based interventions significantly reduced preoperative anxiety, as indicated by decreased scores on the modified Yale Pre-operative Anxiety Scale (p < 0.00001). Anesthesia duration did not significantly differ between the intervention and control groups (p = 0.16). Notably, subgroup analyses revealed a significant reduction in Pediatric Anesthesia Emergence Delirium scores among children under seven years of age (p = 0.001).

CONCLUSIONS

Video-based interventions were linked to lower Pediatric Anesthesia Emergence Delirium scores and a decreased incidence of emergence delirium events. However, these results did not reach statistical significance across the broader sample. Notably, in children under seven, these interventions significantly reduced the scores.

LEVEL OF EVIDENCE

III.

Progress and Frontiers of Research on Dexmedetomidine in Perioperative Medicine: A Bibliometric Analysis

Background

Dexmedetomidine has received increasing attention for its sedative, analgesic, anxiolytic, anti-inflammatory and anti-stress effects in perioperative medicine. Numerous studies have been carried out to explore its influence on perioperative patients.

Objective

This study aimed to identify the most influential literature, trends and hotspots in dexmedetomidine research by bibliometric analysis.

Methods

Articles and reviews related to dexmedetomidine in perioperative medicine were collected from Web of Science Core Collection. VOSviewer and Citespace software were used for bibliometric analysis and data visualization.

Results

A total of 1652 suitable publications were extracted from the database for analysis, including 1,497 articles and 155 reviews. The number of publications in the field of dexmedetomidine research has increased markedly since 2013, with China being the major contributor, followed by United States. BMC Anesthesiology published the highest number of papers on this topic. Anesthesiology ranked first in terms of average citations per paper and co-citation journal. Ji Fuhai was the most prolific author, and Ma Daqing was the most cited authors. The main hotspots during this period were "elderly patients", "postoperative cognitive dysfunction", "injury" and "risk factors".

Conclusion

This study presents an overview of the development related to dexmedetomidine in perioperative medicine using bibliometric analysis. Dexmedetomidine research is thriving and expanding rapidly around the world. The effect of dexmedetomidine on cognitive function has been the latest research hotspot. To advance research in this field, more rigorous and scientific multi-center studies should be designed and further cooperation and academic exchange should be strengthened.

The effect of different dosage of intranasal dexmedetomidine on preventing emergence delirium or agitation in children: A network meta-analysis of randomized controlled trials

BACKGROUND

The clinical evidence for the effects of different doses of intranasal dexmedetomidine on emergence delirium/ emergence agitation (ED/EA) in children is lacking.

METHODS

We searched the PubMed, EMBASE and Cochrane Library from the establishment of the databases until December 30, 2023. All randomized controlled trials that evaluated the effect of different dosage of intranasl dexamedetomidine in children younger than 18 years on postoperative ED/ EA were included. Data analysis was conducted using R 4.3.0.

RESULTS

A total of 15 randomized controlled trials involving 1566 children were included. Compared to 0.5 μg/kg (RR = 4.81, 95%CI = 1.66-13.94), and normal saline (RR = 8.23, 95%CI = 4.63-14.65), intranasal dexmedetomidine at doses of 2 μg/kg significantly reduced the incidence of ED/ EA in children. 2 μg/kg was the most effective dosage in reducing the incidence of ED/ EA (Probability of rank = 0.75), the incidence of severe ED/ EA (Probability of rank = 0.45), and ED/ EA score (Probability of rank = 0.65). Moreover, intranasal dexmedetomidine at doses of 2 μg/kg significantly reduced the PACU pain compared to 0.5 μg/kg (RR = 0.42, 95%CI = -0.22-1.06), 1 μg/kg (RR = 0.18, 95%CI = -0.26-0.63), 1.5 μg/kg (RR = 1.00, 95%CI = -0.54-0.75), and normal saline (RR = 8.23, 95%CI = 4.63-14.65), with a probability of rank = 0.45.

CONCLUSION

2μg/kg intranasal dexmedetomidine is the optimum dose for reducing the occurrence of ED/ EA and postoperative pain. However, further research is required to verify our findings.

Effect of Remimazolam on Emergence Delirium in Children Undergoing Laparoscopic Surgery: A Double-blinded Randomized Trial

BACKGROUND

Preventing emergence delirium is a clinical goal for pediatric anesthesia, yet there is no consensus on its prevention. This study investigated the hypothesis that a continuous infusion or a single bolus of remimazolam can reduce the incidence of emergence delirium in children.

METHODS

A total of 120 children aged 1 to 6 yr were randomly and equally allocated into three groups: group RC, which received a continuous infusion of remimazolam at 1 mg · kg-1 · h-1; group RB, which received a single bolus of remimazolam at 0.2 mg · kg-1 at the beginning of wound closure; and group C, which received a continuous infusion of saline at 1 ml · kg-1 · h-1 and a single bolus of saline at 0.2 ml · kg-1 at the beginning of sutures. The primary outcome was the incidence of emergence delirium assessed by the Pediatric Anesthesia Emergence Delirium scale. Secondary outcomes included the number of rescue propofol administrations in the postanesthesia care unit, recovery time, and adverse events.

RESULTS

Emergence delirium was observed in 14 of 40 (35%) patients in group C, 2 of 40 (5%) patients in group RC (vs. group C, P = 0.001; risk ratio, 95% CI: 0.14, 0.04 to 0.59), and 3 of 39 (7.7%) patients in group RB (vs. group C, P = 0.003; risk ratio, 95% CI: 0.22, 0.07 to 0.71). Ten of 40 patients in group C, 2 of 40 patients in group RC (vs. group C, P = 0.012; risk ratio, 95% CI: 0.20, 0.05 to 0.86), and 2 of 39 patients in group RB (vs. group C, P = 0.014; risk ratio, 95% CI: 0.21, 0.05 to 0.88) needed rescue propofol. No differences in the recovery time and adverse effects were detected.

CONCLUSIONS

Both continuous infusion and single bolus administration of remimazolam can effectively reduce the occurrence of emergence delirium in children.

EDITOR’S PERSPECTIVE

Effects of different doses of intranasal dexmedetomidine on related complications and parents' satisfaction in anesthetized children: a systematic review

BACKGROUND

Agitation/delirium is commonly seen in children after anesthesia, and a proper dose of dexmedetomidine can prevent this complication. This study aimed to investigate the effects of different doses of Dexmedetomidine (DEX) on agitation/delirium and other complications in anesthetized children, providing clinical evidence for dose recommendations of DEX.

METHODS

This study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search was conducted in the Cochrane Library, PubMed, Web of Science, and EMBASE. Two independent researchers performed literature screening, data extraction, and assessed the methodological quality. Data analysis was conducted using R and STATA 16.0.

RESULTS

In the final analysis, 20 randomized controlled trials (RCTs) involving 2521 children were included. The results showed that in comparison to normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX significantly reduced the incidence of post-anesthetic emergence agitation in children with the most effective dose being 2 µg/kg (SUCRA = 0.91). Compared with normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX reduced patient's need for postoperative analgesia, with the most effective dose being 1.5 µg/kg (SUCRA = 0.78). However, 1 µg/kg DEX performed the best in reducing Pediatric Anaesthesia Emergence Delirium (PAED) Scale score (SUCRA = 0.88).

CONCLUSION

Compared with normal saline, intranasal administration of 2 µg/kg DEX and 1.5 µg/kg DEX are the optimal doses to reduce the incidence of agitation and the need for postoperative pain relief in children under general anesthesia. Given effectiveness and safety, intranasal use of 1 µg/kg DEX appears to be the most effective dosage for anesthetized children.

The Median Effective Dose of Dexmedetomidine for the Inhibition of Emergence Delirium in Preschool Children Undergoing Tonsillectomy and/or Adenoidectomy: A Retrospective Dose-response Trial

The incidence of emergence delirium (ED) is higher in preschool children undergoing tonsillectomy and/or adenoidectomy. The purpose of this study was to determine the median effective dose (ED50) of dexmedetomidine (DEX) for the inhibition of ED in preschool children by using probit regression analysis. A total of 140 anesthesia records were retrieved and divided into seven groups based on the infusion rate of DEX: .2, .25, .3, .35, .4, .45, and .5 μg·kg-1·h-1. The Pediatric Anesthesia Emergence Delirium Scale (PAEDS) was used to assess ED in preschool children, and ED was defined as a PAEDS score ≥ 10. Probit regression analysis revealed that the ED50 and ED95 of DEX were .31 μg·kg-1·h-1 (95% CI: .29-.35) and .48 μg·kg-1·h-1 (95% CI: .44-.56), respectively. Probit(p) = -2.84 + 9.28 × ln (Dose), (χ2 = 1.925, P = .859). The PAEDS score was significantly increased in the ED group, and the rate of bradycardia was significantly decreased in the ED group compared with the without ED group (27.3% vs 54.1%, P = .02). DEX can effectively inhibit the ED in preschool children undergoing tonsillectomy and/or adenoidectomy, however, bradycardia was the main complication.

The Effect of Intranasal Dexmedetomidine on Emergence Delirium Prevention in Pediatric Ambulatory Dental Rehabilitation Under General Anesthesia: A Randomized Clinical Trial

Purpose

Sevoflurane is the preferred anesthetic agent for induction and maintenance of ambulatory surgery due to its property of fast onset and recovery. However, it has been recognized as one of the major contributors of emergence delirium. The aim of this study was to evaluate the preventive effect of intranasal dexmedetomidine on the occurrence of emergence delirium in pediatric patients under general anesthesia with sevoflurane.

Patients and Methods

Ninety pediatric patients undergoing dental rehabilitation under sevoflurane anesthesia were enrolled in this study. The patients were divided into three groups (n=30 each in the 2 μg/kg dexmedetomidine, 1 μg/kg dexmedetomidine, and control with saline groups). The same volume (0.02mL/kg) of the mixed solution was dropped into the nasal cavity of the children 30 minutes before surgery. We used the Pediatric Anesthesia Emergence Delirium Scale (PAED) to assess the level and incidence of delirium in the post-anesthesia care unit.

Results

Compared with the control group, prophylactic use of different dosages of intranasal dexmedetomidine significantly reduces the incidence of ED and severe ED in PACU (P<0.001). Intranasal administration of 2 μg/kg dexmedetomidine was associated with a better acceptance of mask induction and a better tolerance of separation with parents.

Conclusion

Both 2 μg/kg and 1 μg/kg intranasal dexmedetomidine can achieve ED preventive effects in PACU in dental rehabilitation under general anesthesia. A dosage of 2 μg/kg is more effective in preventing severe ED and providing better mask acceptance.

Effects of Pharmacological Intervention on Recovery After Sevoflurane Anesthesia in Children: a Network Meta-analysis of Randomized Controlled Trials

Sevoflurane, commonly administered to children as anesthesia, often leads to emergence delirium (ED). Currently, a consensus is lacking among clinicians regarding pharmacological interventions to improve recovery. To determine an effective approach, we compared the effects of several drugs in lowering the incidence of ED after sevoflurane anesthesia in children.We searched online databases for relevant randomized controlled trials (59 studies selected; 5199 NMA-eligible participants) and performed a frequentist network meta-analysis (NMA). This study was registered on PROSPERO (number CRD: 42022329939).All included studies had a low to moderate risk of overall bias. The incidence of ED after sevoflurane anesthesia in children differed according to other drugs administered, and were ranked from high to low according to the surface under the cumulative ranking curve (SUCRA).Sufentanil (91.2%) and dexmedetomidine (77.6%) were more likely to reduce the incidence (SUCRA value) of ED, whereas the placebo (6.5%), ramelteon (11.1%), and magnesium (18%) were less likely to reduce the incidence of ED. Remifentanil (89.3%) ranked first in shortening emergence time, followed by placebo (82.4%) and ketamine (69.7%). Placebo shortened extubation time, followed by remifentanil (66.5%) and alfentanil (61.4%).Sufentanil and remifentanil lowered sevoflurane-induced ED incidences among children and shortened the emergence time more effectively than other drugs. Most adjuvant drugs that are combined with sevoflurane either do not change or may even prolong extubation time. Further research and clinical trials are required to support and update these conclusions.

The effect of intranasal dexmedetomidine administration on emergence agitation or delirium in pediatric patients after general anesthesia: A meta-analysis of randomized controlled trials

BACKGROUND

Emergence agitation or delirium can occur in pediatric patients after anesthesia. Dexmedetomidine is known to reduce the impairment of postoperative cognitive function.

AIMS

This study aimed to identify the role of intranasal administration of dexmedetomidine in lowering the development of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

METHODS

Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. The primary outcome was the proportion of patients who underwent emergence agitation or emergence delirium after the surgery. Secondary outcomes included emergence time and incidence of postoperative nausea and/or vomiting. We estimated the odds ratio and mean difference with 95% confidence intervals for the determination of effect size using a random-effects model.

RESULTS

In total, 2103 pediatric patients from 20 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 13.6% in the dexmedetomidine group and 33.2% in the control group. The pooled effect size revealed that intranasal dexmedetomidine administration significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery under general anesthesia (odds ratio 0.25, 95% confidence interval 0.18-0.34; p = .0000; I²  = 37.74%). Additionally, significant difference was observed in emergence time between the two groups (mean difference 2.42, 95% confidence interval 0.37-4.46; p = .021; I²  = 98.40%). Children in the dexmedetomidine group had a significantly lower incidence of postoperative nausea and/or vomiting than those in the control group (odds ratio 0.39, 95% confidence interval 0.24-0.64; p = .0002; I²  = 0.00%).

CONCLUSIONS

Intranasal dexmedetomidine reduced the incidence of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

The optimum time for intravenous cannulation after induction with sevoflurane in children premedicated with dexmedetomidine

BACKGROUND

Inhalation anesthesia is a frequently used method for anesthesia induction, especially in young children. No information is available on the optimum time for safe intravenous cannulation after inhalational induction in children with dexmedetomidine premedication. The purpose of the present study was to determine the optimal time for intravenous cannulation after induction of anesthesia with sevoflurane and nitrous oxide in children premedicated with intranasal dexmedetomidine.

METHODS

This prospective and observational study was conducted by using the up-down sequential method. Children, who were aged 2-6 years with ASA physical status I, and who underwent inhalation induction for elective surgery were included in the study. Anesthesia was induced with sevoflurane and nitrous oxide after the premedication with intranasal dexmedetomidine (2 mcg/kg). Intravenous cannulation was attempted on the dorsum of the hand by an experienced anesthesiologist 4 min after the loss of the eyelash reflex in the first patient. The procedure was considered successful in patients without any movement, cough, or laryngospasm. The waiting time for cannulation was increased by 15 s if the procedure was not successful in the previous patient, and on the contrary, it was reduced by 15 s if the procedure was successful in the previous patient. The probit test was used in the analysis of up-down sequences.

RESULTS

In the present study in which a total of 40 patients were included, the effective cannulation time was found to be 14.40 s (95% confidence limits, 1.30-27.82 s) in 50% of the patients, and the effective cannulation time was found as 84.64 s (95% confidence limits, 69.61-218.26 s) in 95% of the patients.

CONCLUSIONS

In conclusion, we suggest that the appropriate time for cannulation is 85 s (1.45 min) after the loss of eyelash reflex in children sedated with dexmedetomidine and induction with sevoflurane and nitrous oxide-oxygen mixture.

Effects of preoperative nasal spray esketamine on separation anxiety and emergence agitation in pediatric strabismus surgery: A randomized clinical trial

OBJECTIVE

To investigate the effects of preoperative nasal spray esketamine on separation anxiety and postoperative emergence agitation in pediatric strabismus surgery.

METHOD

Ninety children aged 3 to 6 years who underwent elective strabismus surgery were randomly divided into 3 groups that received 0.5 mg/kg (group S1), 1 mg/kg of esketamine (group S2), and the same volume of normal saline (group C) by nasal spray 10 minutes before surgery. The observation indicators of this test include the Ramsay sedation score, separation anxiety score, mask induction score, and the incidences of postoperative emergence agitation. Patient's heart rate, blood oxygen, post anesthesia care unit stay time, and any adverse events were recorded.

RESULTS

The Ramsay sedation score was significantly lower in group C than those in groups S1 and S2 (P < .001). The separation anxiety scores and the mask induction scores were significantly higher in group C than those in groups S1 and S2 (P < .001). The incidences of emergence agitation in groups S1 and S2 were significantly lower than that in C group (P < .001). No obvious clinical complication was observed.

CONCLUSION

Preoperative nasal spray esketamine reduced the preoperative separation anxiety and decrease emergence agitation in pediatric strabismus surgery.

Atomised intranasal dexmedetomidine versus oral melatonin in prevention of emergence delirium in children undergoing ophthalmic surgery with sevoflurane: A randomised double-blind study

BACKGROUND

Melatonin and dexmedetomidine have both been used as a premedication to decrease emergence delirium in children. The effectiveness of oral melatonin, compared with atomised intranasal dexmedetomidine, in this role is not well studied.

OBJECTIVE

To study the efficacy of pre-operative atomised intranasal dexmedetomidine versus oral melatonin in children scheduled for ophthalmic surgery under sevoflurane.

DESIGN

A prospective, randomised, double-blind trial.

SETTING

Ophthalmic surgery in a university teaching hospital, April 2021 to October 2021.

PATIENTS

A total of 120 children undergoing ophthalmic surgery with sevoflurane anaesthesia.

INTERVENTION

Children were randomised to receive pre-operative intranasal dexmedetomidine 2 μg/kg via an atomiser device (dexmedetomidine group) or oral melatonin 0.5 mg kg -1 (melatonin group), 45 min before surgery.

OUTCOMES MEASURED

The primary outcome was the incidence of emergence delirium assessed by the Paediatric Anaesthesia Emergence Delirium scale. Secondary outcomes included pre-operative sedation, quality of inhalational induction, postoperative sedation and pain.

RESULTS

The incidence of emergence delirium was lower in the dexmedetomidine group than in the melatonin group (17 versus 37%, relative risk 0.45, 95% CI: 0.24 to 0.88; P  = 0.01). Children in the dexmedetomidine group were more sedated following premedication and in the postanaesthesia care unit ( P  < 0.05). Postoperative pain scores were lower in the dexmedetomidine group than in the melatonin group: 0 [0 to 3] versus 2.5 [0-4], ( P  = 0.01). The requirement for and dose of rescue fentanyl analgesia postoperatively was comparable between the two groups.

CONCLUSION

Atomised intranasal dexmedetomidine significantly reduced emergence delirium in paediatric opthalmic procedures under sevoflurane anaesthesia compared to oral melatonin.

TRIAL REGISTRATION

Clinical Trials Registry of India CTRI/2021/03/032388 ( www.ctri.nic.in ).

Efficacy of different doses of intranasal dexmedetomidine in preventing emergence agitation in children with inhalational anaesthesia: A prospective randomised trial

BACKGROUND

Emergence agitation is a common paediatric complication after inhalational anaesthesia. Intranasal dexmedetomidine can prevent emergence agitation effectively, but the optimal dose is uncertain.

OBJECTIVE

The aim of our study was to investigate the 95% effective dose (ED 95 ) of intranasal dexmedetomidine for the prevention of emergence agitation after inhalational anaesthesia for paediatric ambulatory surgery.

DESIGN

A prospective, randomised, placebo-controlled, double-blind, clinical trial.

SETTING

The study was conducted in Guangzhou Women and Children's Medical Center in China from August 2017 to December 2018.

PATIENTS

Three hundred and eighteen children scheduled for ambulatory surgery were enrolled into two age groups of less than 3 years and at least 3 years.

INTERVENTIONS

The children in each age group were randomised into five equal subgroups to receive either intranasal dexmedetomidine 0.5, 1.0, 1.5 or 2.0 μg kg -1 (Groups D 0.5 , D 1.0 , D 1.5 and D 2.0 ), or intranasal isotonic saline (group C) after induction.

MAIN OUTCOME MEASURES

The primary outcome was the ED 95 dose of intranasal dexmedetomidine for preventing emergence agitation after inhalational anaesthesia for paediatric ambulatory surgery.

RESULTS

The incidences of emergence agitation for Groups C, D 0.5 , D 1.0 , D 1.5 and D 2.0 were 63, 40, 23, 13 and 3% in children less than 3 years, and 43, 27, 17, 7 and 3% in children at least 3 years. The ED 95 of intranasal dexmedetomidine for preventing emergence agitation was 1.99 μg kg -1 [95% confidence interval (CI), 1.83 to 3.80 μg kg -1 ] in children less than 3 years, and 1.78  μg kg -1 (95% CI, 0.93 to 4.29 μg kg -1 ) in children at least 3 years. LMA removal time for groups D 1.5 and D 2.0 was 9.6 ± 2.2 and 9.7 ± 2.5 min, respectively, for children less than 3 years, and 9.4 ± 2.0 and 9.9 ± 2.7 min in children at least 3 years, respectively. Length of stay in the postanaesthesia care unit for Groups D 1.5 and D 2.0 was 34.3 ± 9.6 and 37.1 ± 11.2 min, respectively, in children less than 3 years, and 34.7 ± 10.2 and 37.3 ± 8.3 min in children at least 3 years, respectively. These times were longer in the D 1.5 and D 2.0 subgroups than in the control subgroup in the two age groups of less than 3 years and at least 3 years, respectively: 7.2 ± 1.9 min in children less than 3 years and 7.3 ± 2.5 min in children at least 3 years for LMA removal time, 22.2 ± 7.9 min in children less than 3 years and 22.0 ± 7.7 min in children at least 3 years for PACU stay time in control subgroup, respectively ( P  < 0.05).

CONCLUSION

Intranasal dexmedetomidine prevented emergence agitation after paediatric surgery in a dose-dependent manner. The optimal dose of intranasal dexmedetomidine for preventing emergence agitation was higher in younger children.

TRIAL REGISTRY

chictr.org.cn: ChiCTR-IOR-17012415.

A systematic review and meta-analysis on the efficacy and safety of dexmedetomidine combined with sevoflurane anesthesia on emergence agitation in children

BACKGROUND

The incidence of restlessness in the wake-up period of sevoflurane inhalation anesthesia is high. Although many studies have explored the relationship between dexmedetomidine and restlessness in the wake-up period of sevoflurane anesthesia in children, they can't keep consistent conclusions and lack evidence-based medical evidence. Meta-analysis was conducted to explore the efficacy and safety of dexmedetomidine in the treatment of restlessness during the recovery period of sevoflurane anesthesia in children, and to provide reference for clinic.

METHODS

Relevant articles were retrieved from PubMed, Embase, MEDLINE, Science Direct, The Cochrane Library, the Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, the Chinese Science and Technology Periodical Database, and the Chinese BioMedical Literature Database (CBM). The Chinese and English search keywords included "dexmedetomidine", "children", "sevoflurane", and "emergence agitation". The articles included were independently evaluated and cross-checked by 2 professionals in strict accordance with the 5 evaluation criteria for randomized controlled trials (RCTs) in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.0.1).

RESULTS

A total of 16 articles were included in this meta-analysis. Of the 16 RCTs, 14 described the generation of random sequences in detail, 8 described allocation concealment in detail, no patient blinding was described due to different surgical methods, 8 articles used operator blinding, and all 16 articles had complete outcome measures. The incidence of emergence agitation in the 0.5 µg/kg dexmedetomidine group was significantly lower than that in the control group, and the difference was statistically significant [odds ratio (OR) =0.22, 95% CI: 0.13, 0.40, P<0.00001]. The incidence of analgesic rescue in the experimental group was significantly lower than that in the control group, and the difference was statistically significant (OR =0.29, 95% CI: 0.13, 0.63, Z =3.13, P=0.002). The incidence of postoperative nausea and vomiting in the experimental group was significantly lower than that in the control group, and the difference was statistically significant (OR =0.33, 95% CI: 0.20, 0.55, Z =4.29, P<0.0001).

DISCUSSION

The results of this meta-analysis confirmed that dexmedetomidine could reduce the incidence of emergence agitation, postoperative analgesic rescue, and nausea and vomiting in children after sevoflurane anesthesia.

Hes-related family BHLH transcription factor with YRPW motif 1-activated proteasome 26S subunit, non-ATPase 14 regulates trophoblast function and endometrial angiogenesis

Proteasome 26S subunit, non-ATPase 14 (PSMD14) expression has been previously reported to be reduced in patients with pre-eclampsia (PE). The present study investigated the interaction network associated with the role of PSMD14 in PE. Reverse transcription-quantitative PCR (RT-qPCR) and western blotting were performed to determine the transfection efficacy following plasmid-based gene transfer of PSMD14 into HTR-8/SVneo cells. Cell proliferation was measured using an MTT assay and 5-ethynyl-2'-deoxyuridine staining. The expression of proliferation-related proteins, including Ki67 and PCNA, was determined using western blotting. Wound healing and Transwell assays were performed to measure cell invasion and migration, whilst the expression of migration-related proteins, including MMP2 and MMP9, was measured using western blotting. The angiogenesis of HUVECs following treatment with the HTR-8/SVneo cell culture supernatant was examined using tube formation assay. Following overexpression of Hes-related family BHLH transcription factor with YRPW motif 1 (HEY1) by transfection of pcDNA3.1 expression vector containing full-length human HEY1 or knockdown by transfection of shRNA plasmids targeting HEY1, the expression of HEY1 and PSMD14 was detected using RT-qPCR and western blotting. The potential interaction between HEY1 and the PSMD14 promoter was examined using dual-luciferase reporter and chromatin immunoprecipitation assays. PSMD14 overexpression was found to promote the proliferation, invasion, migration of HTR-8/SVneo cells and the angiogenesis of HUVECs following treatment with the HTR-8/SVneo cell culture supernatant, accompanied by enhanced expression of proliferation and migration-related proteins. Furthermore, the transcription factor HEY1 activated the expression of PSMD14. Knocking down HEY1 expression partially reversed the promoting effects of PSMD14 overexpression on the proliferation, invasion, migration, angiogenesis, proliferation and migration-related protein expression in trophoblasts. In conclusion, HEY1-activated PSMD14 promoted trophoblast proliferation, invasion and angiogenesis. Therefore, HEY1 and PSMD14 can be potential targets for PE treatment.

Meta-analysis of visual pretreatment for the prevention of emergence delirium in children undergoing ophthalmic surgery

Objective: To evaluate the role of visual pretreatment in preventing emergence delirium in children receiving ophthalmic surgery. Methods: Four randomized controlled trials were identified in four databases, and a meta-analysis was conducted using RevMan 5.3. Results: The meta-analysis demonstrated a significantly lower incidence of postoperative emergence delirium (risk ratio: 0.39; 95% CI: 0.31-0.49) and propofol rescue (risk ratio: 0.29; 95% CI: 0.13-0.65) but comparable modified Yale Preoperative Anxiety Scale score (mean difference: -3.66; 95% CI: -9.96 to 2.65) and incidence of adverse events in the visual pretreatment group. Conclusion: Visual pretreatment is effective in preventing postoperative emergence delirium in children undergoing ophthalmic surgery without significant adverse effects and can also decrease the incidence of propofol rescue.

Comparison of the Effects of Oral Midazolam and Intranasal Dexmedetomidine on Preoperative Sedation and Anesthesia Induction in Children Undergoing Surgeries

Background and Purpose: Premedication with either oral midazolam or intranasal dexmedetomidine prior to surgery remains less than ideal. The aim of this study was to investigate whether the combination of those two drug regimens would have any beneficial effects on the preoperative sedation and the children’s compliance during anesthesia inhalation induction.

Experimental Approach: One hundred thirty-eight children aged 2–6 years were randomly allocated into three groups: Group M with oral midazolam 0.5 mg kg⁻¹, Group D with intranasal dexmedetomidine 2 μg kg⁻¹, and Group M + D with intranasal dexmedetomidine 1 μg kg⁻¹ plus oral midazolam 0.5 mg kg⁻¹. The primary outcome was the children’s compliance during inhalation induction with sevoflurane. The secondary outcomes included the preoperative sedative effects, behavior scores, parental separation anxiety scores, and the postoperative incidence of emergence agitation and recovery time.

Results: Subjects in Group M + D showed higher satisfaction scores of compliance (p = 0.0049) and mask acceptance (MAS) (p = 0.0049) during anesthesia inhalation induction. Subjects in Group M + D had a significantly shorter time than those in Groups M and D to achieve the desired sedation level (p < 0.001) and remained at a higher sedation score in the holding area and up to the anesthesia induction after drug administration (p < 0.001).

Conclusion and Implications: We conclude that pediatric patients premedicated with intranasal dexmedetomidine 1 μg kg⁻¹ plus oral midazolam 0.5 mg kg⁻¹ had significantly improved anesthesia induction compliance, and quicker onset to achieve and maintain a satisfactory level of sedation than those premedicated separately with two drugs. Therefore, the combined premed regimen is a greater choice when we are expecting a higher quality of sedation and a smoother anesthesia induction in children undergoing the surgeries.

Determination of the Median Effective Dose of Dexmedetomidine for the Prevention of Emergence Agitation in Geriatric Patients Undergoing Major Open Surgery With General Anesthesia: A Prospective, Double-Blinded, Dose-Response Trial

Dexmedetomidine can effectively decrease the incidences of emergence agitation (EA) in adult patients, but there are major side effects related to increased dose of dexmedetomidine. The purpose of this study was to determine the median effective dose of dexmedetomidine in the prevention of EA among geriatric patients undergoing major open surgery with general anesthesia. A total of 50 geriatric patients were enrolled in this study. Dexmedetomidine 0.5 μg·kg⁻¹·h⁻¹ continuous intravenous infusion was administered to the first patient. The next dose was increased or decreased by .05 depending on the response of the previous patient, according to the Dixon up-and-down method. An “effective” or “ineffective” response was determined based on the Riker sedation-agitation score (RSAS), we defined “effective” as RSAS<5, and “ineffective” as RSAS≥5. The ED50 of dexmedetomidine in prevention of EA was .30 μg·kg⁻¹·h⁻¹ (95% CI, .27–.33) and the predicted ED95 was .42 μg·kg⁻¹·h⁻¹ (95% CI, .38–.51). The incidence of bradycardia was significantly increased in the group without EA compared to the group with EA (57.1% vs 13.6%, P = .002). The ED50 of dexmedetomidine in prevention of EA was .30 μg·kg⁻¹·h⁻¹ (95% CI, .27–.33) and the predicted ED95 was .42 μg·kg⁻¹·h⁻¹ (95% CI, .38–.51). Bradycardia was the main complication.

Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis

STUDY OBJECTIVE

This updated network meta-analysis aims at exploring whether the concurrent use of midazolam or antiemetics may enhance the efficacy of other pharmacological regimens for delirium prophylaxis in pediatric population after general anesthesia (GA).

DESIGN

Network meta-analysis (PROSPERO registration: CRD42020179483).

SETTING

Postoperative recovery area.

PATIENTS

Pediatric patients undergoing GA with sevoflurane.

INTERVENTIONS

Pharmacological interventions applied during GA with sevoflurane.

MEASUREMENTS

This network meta-analysis of randomized controlled trials (RCTs) was conducted with a frequentist model. PubMed, Embase, ProQuest, ScienceDirect, Cochrane CENTRAL, ClinicalKey, Web of Science, and ClinicalTrials.gov were searched from their inception dates to April 12, 2020, for RCTs of either placebo-controlled or active-controlled design containing information on the incidence of emergence delirium in pediatric patients undergoing sevoflurane anesthesia.

MAIN RESULTS

Seventy studies comprising 6904 participants were included for the analysis of 30 pharmacological interventions. Based on surface under the cumulative ranking curve (SUCRA) analysis, midazolam was ranked the lowest in therapeutic effect (SUCRA: 20%), while antiemetics as a monotherapy had no effect on delirium prophylaxis. However, there was a trend that most combination therapies with midazolam or antiemetics were superior to monotherapies for delirium prophylaxis. Subgroup analyses based on age (i.e., ≤7 years) and a validated scoring system (i.e., the Pediatric Anesthesia Emergence Delirium scale) for delirium also suggested a better efficacy of combination therapies than monotherapies. Overall, combination therapies with midazolam or antiemetics did not have a negative impact on the incidence of postoperative nausea and vomiting, length of stay in the postanesthesia care unit, or time to extubation. The dexmedetomidine-midazolam-antiemetic combination was the most effective strategy for the prevention of emergence delirium.

CONCLUSIONS

This network meta-analysis suggested that the incorporation of midazolam or antiemetics as adjuncts for combination therapies may have synergistic effects against pediatric postoperative emergence delirium. Future large-scale placebo-controlled RCTs are warranted to validate our findings.

Comparison of Low-Dose Sevoflurane Inhalation With Intranasal Ketamine as Rescue Sedation After Intranasal Dexmedetomidine Failure in Outpatient Children Undergoing MRI: A Randomized Control Trial

PURPOSE

The present study aimed to evaluate the effectiveness and safety of low-dose inhalation of sevoflurane through a face mask as a rescue remedy for sedation compared with intranasal ketamine in outpatient children undergoing magnetic resonance imaging (MRI).

DESIGN

A prospective randomized control study. A total of 336 children scheduled for 3.0T MRI but were inadequately sedated after initial intranasal dexmedetomidine (3 μg/kg) were randomly divided into two groups.

METHODS

We used the following protocol for each group: group S, inhalation of low-dose sevoflurane (end-expiratory concentration, 0.4%) through a face mask; group K, intranasal ketamine (2 mg/kg). The success rates were compared between groups as the primary endpoint. The induction time, scan time, recovery time, time to return to baseline functional status, parental and radiologist satisfaction, occurrence of adverse events, and other secondary endpoints were also compared.

FINDINGS

Successful rescue sedation in groups S and K was achieved in 160 (95.2%) and 138 (82.1%) patients, respectively. Compared with group K, group S needed fewer repeat sequences and showed a significantly shorter induction time (5.7 ± 0.5 vs. 10.9 ± 2.7 min; P < 0.001), recovery time (27.4 ± 6.3 vs. 53.8 ± 15.2 min; P < 0.001), and time to return to baseline functional status (3.4 ± 0.6 vs. 6.1 ± 1.1 h; P < 0.001). Radiologist satisfaction, parental satisfaction, and parental desire to repeat the same sedation method were significantly higher in the sevoflurane group.

CONCLUSION

Our results suggest that the inhalation of low-dose sevoflurane through a face mask can provide effective and safe rescue sedation in 1- to 6-year-old outpatient children undergoing MRI, and yields a higher success rate, shorter induction and recovery times, and higher satisfaction than the intranasal ketamine method.

The Safety and Efficacy Evaluation of Dexmedetomidine for Procedural Sedation and Postoperative Behaviors in Pediatric Populations: A Systematic Review and Meta-analysis

BACKGROUND

This study systematically evaluated the safety and efficacy of dexmedetomidine for procedural sedation and postoperative behaviors in a pediatric population as well as whether the results met the information required to draw conclusions.

OBJECTIVE

To evaluate the safety and efficacy evaluation of dexmedetomidine for procedural sedation and postoperative behaviors in a pediatric population.

METHODS

PubMed, Cochrane library, Web of Science and Ovid MEDLINE were searched to obtain randomized controlled trials (RCTs) comparing dexmedetomidine with control medicine and comparing different doses of dexmedetomidine.

RESULTS

There were a total of 16 RCTs for a total of 3240 patients. Dexmedetomidine slowed down the heart rate (HR; mean difference: -13.27; 95% CI: -16.41 to 10.14; P < 0.001) and reduced postoperative delirium (risk ratio [RR]: 0.31; 95% CI: 0.20-0.50; P < 0.001), the number of pain patients (RR: 0.48; 95% CI: 0.30-0.75; P = 0.002), and desaturation (RR: 0.34; 95% CI: 0.13-0.89; P = 0.03) compared with the control group. The limitation was that it was difficult to determine the range of low- and high-dose dexmedetomidine.

CONCLUSION AND RELEVANCE

Dexmedetomidine slowed down intraoperative HR within the normal range, which might reduce myocardial oxygen consumption. It reduced postoperative pain and postoperative complications: delirium and desaturation. Dexmedetomidine showed no dose-dependent increase in the procedural sedation time of pediatric patients. Clinically, dexmedetomidine can improve pediatric procedural sedation and postoperative behavior, and it can be considered as a related medicine for safety in pediatric surgery.

Effect of Dexmedetomidine in children undergoing general anaesthesia with sevoflurane: a meta-analysis and systematic review

Objective

The sedative effects of dexmedetomidine (Dex) are similar to natural sleep, with easy wakening following Dex administration, and Dex has minor effects on breathing, reducing emergence agitation in children. The aim of this study was to systematically evaluate the effects of Dex on recovery quality in children following general anaesthesia with sevoflurane, to aid clinical decision making.

Methods

Relevant randomized controlled trials published before August 2019 were searched and selected from databases. Two researchers independently screened the literature, extracted data, and assessed included studies for bias risk. Meta-analysis was performed using Stata 14.0 software.

Results

The study included 24 publications. Following general anaesthesia by sevoflurane, Dex was associated with reduced occurrence of emergence agitation (odds ratio [OR] 0.16, 95% confidence interval [CI] 0.11, 0.25) and nausea and vomiting (OR 0.40, 95% CI 0.24, 0.60), along with shortened eye-opening time (standardized mean difference [SMD] 0.72, 95% CI 0.41, 1.03), shortened extubation time (SMD 0.54, 95% CI 0.28, 0.81), and reduced duration of post-anaesthesia care unit (PACU) stay (SMD 0.29, 95% CI 0.08, 0.51) versus placebo.

Conclusion

Dexmedetomidine has positive effects on recovery quality in children undergoing general anaesthesia with sevoflurane.

Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis

BACKGROUND

Beneficial effects of dexmedetomidine (DEX) against emergence agitation (EA) in children remain controversial. We performed a more comprehensive meta-analysis to evaluate the protective effect of different administration routes, timing, patterns, and doses of DEX on EA in children.

METHODS

The randomized controlled trials about DEX preventing EA in children were searched in PubMed, Cochrane Library, Embase, and Web of Sciences up to October 7, 2020. The traditional meta-analysis and subgroup analysis were performed to study the influence of DEX on EA in children. The sequential trial analysis (TSA) further analyzed the pooled results to evaluate meta-analyses' robustness. Grading of recommendation, assessment, development, and evaluation (GRADE) was used to assess evidence quality.

RESULTS

Sixty-seven studies with 5,688 pediatric patients were included. DEX significantly decreased EA in children compared to placebo [RR 0.29, 95% confidence intervals (CI): 0.25-0.34] and midazolam (RR 0.34, 95% CI: 0.25-0.45), with firm evidence from TSA. Notably, using DEX significantly reduced severe EA incidence (RR 0.23, 95% CI: 0.16-0.32), with firm evidence by TSA and high quality of GRADE. Pre-specified subgroup analyses revealed firm and high-quality evidence for a reduction of EA, only if the perineural route administers DEX (RR 0.24, 95% CI: 0.14-0.41), as premedication (RR 0.27, 95% CI: 0.20-0.36), as continuous dosage (RR 0.25, 95% CI: 0.18-0.33), at high dose (RR 0.24, 95% CI: 0.18-0.31). The pooled results also showed that DEX reduced the incidence of PONV compared to placebo (RR 0.43, 95% CI: 0.33-0.55). Evidence for DEX's influence on other secondary outcomes (emergence time, time in PACU, rescue analgesia, hypotension, and bradycardia) is insufficient to draw any conclusion.

CONCLUSIONS

Our findings confirm the beneficial effects of DEX on EA, severe EA, and PONV in children. There was firm and high-quality evidence for the efficacy of DEX in preventing EA in children when perineural routes administered DEX, as premedication, as continuous dosage, and at a high dose. The best dose, route, patterns, and timing of DEX and influence on other outcomes call for further studies.

Evaluation of Intranasal Dexmedetomidine as a Procedural Sedative for Ophthalmic Examination of Children With Glaucoma

PRECIS

This study evaluated 2 doses of intranasal dexmedetomidine (IND) (3.0 and 3.5 µg/kg) as a procedural sedative for postoperative examination of children with glaucoma. A dose of 3.5 µg/kg was more efficacious and obviated the need for repeated general anesthesia.

PURPOSE

This study was carried out to determine the safety and effective dose of IND as a procedural sedative for postoperative follow-up examinations after glaucoma surgery in children in place of repeated examination under anesthesia.

MATERIALS AND METHODS

In this prospective randomized double-blinded interventional study, consecutive children aged 6 months to 6 years were randomized to receive 3.0 and 3.5 µg/kg IND using a mucosal atomizer device in the preoperative area of the operating room, under continuous monitoring of vital signs. Intranasal midazolam 0.25 mg/kg was used as a rescue agent in case of inadequate sedation, and general anesthesia was administered in case of persistent failure. All infants underwent a complete anterior and posterior segment evaluation including intraocular pressure and corneal diameter measurements.

RESULTS

A total of 30 and 31 children aged 23.9±15.0 and 19.2±10.1 months, respectively, received 3.0 and 3.5 µg/kg IND. Adequate sedation was possible in 18 of 30 (60%) children receiving 3.0 µg/kg and 24 of 31 (77.4%) receiving 3.5 µg/kg IND alone (P=0.17). In combination with midazolam, successful sedations were 86.6% versus 100%, respectively (P=0.052). One patient in the 3.5 µg/kg group had ventricular arrhythmia, reversed with dextrose-saline infusion and injection glycopyrrolate.

CONCLUSIONS

IND appears to be a safe and effective procedural sedative for postoperative follow-up examinations of pediatric glaucoma patients at doses of 3 and 3.5 µg/kg. The dose of 3.5 µg/kg was successful in more children.

Ketamine Enhances Intranasal Dexmedetomidine-Induced Sedation in Children: A Randomized, Double-Blind Trial

Purpose

To compare the efficacy of intranasal dexmedetomidine and dexmedetomidine-ketamine premedication in preschool children undergoing tonsillectomy.

Patients and Methods

We enrolled 66 children with American Society of Anesthesiologists physical status I or II, aged 3–7 years undergoing tonsillectomy. Patients were randomly allocated to receive intranasal premedication with either dexmedetomidine 2 μg kg⁻¹ (Group D) or dexmedetomidine 2 μg kg⁻¹ and ketamine 2 mg kg⁻¹ (Group DK). The primary outcome was the sedation level assessed by the Modified Observer’s Assessment of Alertness/Sedation Scale (MOAA/S) 30 min after intervention. The minimal clinically relevant difference in the MOAA/S score was 0.5. Secondary outcomes included sedation onset time, parental separation anxiety, acceptance of mask induction, emergence time, emergence delirium, postoperative pain intensity, length of stay in the post-anesthesia care unit (PACU), and adverse effects.

Results

At 30 min after premedication, the MOAA/S score was lower in Group DK than in Group D patients (median: 1.0, interquartile range [IQR]: 1.0–2.0 vs median: 3.0, IQR: 2.0–3.0; P<0.001), with a median difference of 1.0 (95% confidence interval [CI]: 1.0–2.0, P<0.001). Patients in Group DK showed considerably faster onset of sedation (15 min, 95% CI: 14.2–15.8 min) than Group D (24 min, 95% CI: 23.2–24.8 min), with a median difference of 8.0 min (95% CI: 7.0–9.0 min, P<0.001). Both parental separation and facemask acceptance scores were lower in Group DK than in Group D patients (P=0.012 and P=0.001, respectively). There was no significant difference in emergence time, incidence of emergence delirium, postoperative pain scores, and length of stay in the PACU between the two groups.

Conclusion

Intranasal premedication with a combination of dexmedetomidine and ketamine produced better sedation for pediatric tonsillectomy than dexmedetomidine alone.

The Effect of Dexmedetomidine on Emergence Agitation or Delirium in Children After Anesthesia-A Systematic Review and Meta-Analysis of Clinical Studies

Background: We conducted this systematic review and meta-analysis to investigate the clinical effect of dexmedetomidine in preventing pediatric emergence agitation (EA) or delirium (ED) following anesthesia compared with placebo or other sedatives. Methods: The databases of Pubmed, Embase, and Cochrane Library were searched until 8th January 2020. Inclusion criteria were participants with age<18 years and studies of comparison between dexmedetomidine and placebo or other sedatives. Exclusion criteria included adult studies; duplicate publications; management with dexmedetomidine alone; review or meta-analysis; basic research; article published as abstract, letter, case report, editorial, note, method, or protocol; and article presented in non-English language. Results: Fifty-eight randomized controlled trials (RCTs) and five case-control trials (CCTs) including 7,714 patients were included. The results showed that dexmedetomidine significantly decreased the incidence of post-anesthesia EA or ED compared with placebo [OR = 0.22, 95% CI: (0.16, 0.32), I 2 = 75, P < 0.00001], midazolam [OR = 0.36, 95% CI: (0.21, 0.63), I 2 = 57, P = 0.0003], and opioids [OR = 0.55, 95% CI: (0.33, 0.91), I 2 = 0, P = 0.02], whereas the significant difference was not exhibited compared with propofol (or pentobarbital) [OR = 0.56, 95% CI: (0.15, 2.14), I 2 = 58, P = 0.39], ketamine [OR = 0.43, 95% CI: (0.19, 1.00), I 2 = 0, P = 0.05], clonidine [OR = 0.54, 95% CI: (0.20, 1.45), P = 0.22], chloral hydrate [OR = 0.98, 95% CI: (0.26, 3.78), P = 0.98], melatonin [OR = 1.0, 95% CI: (0.13, 7.72), P = 1.00], and ketofol [OR = 0.55, 95% CI: (0.16, 1.93), P = 0.35]. Conclusion: Compared with placebo, midazolam, and opioids, dexmedetomidine significantly decreased the incidence of post-anesthesia EA or ED in pediatric patients. However, dexmedetomidine did not exhibit this superiority compared with propofol and ketamine. With regard to clonidine, chloral hydrate, melatonin, and ketofol, the results needed to be further tested due to the fact that only one trial was included for each control drug.

Emergence Delirium in Perioperative Pediatric Care: A Review of Current Evidence and New Directions

Emergence delirium (ED) is defined as psychomotor agitation and delirium that typically occurs within 45 min from emergence of anesthesia. Preoperative patient conditions such as anxiety and confusion are risk factors for the development of postoperative ED. Common signs of ED are general non-purposeful resistive movements such as kicking, pulling, flailing as well as lack of eye contact and general lack of awareness of surroundings. The use of volatile anesthetics (VA) is contributory, while the use of total intravenous anesthetic techniques (TIVA) may help to reduce the incidence of emergence delirium. Furthermore, various pharmacologic strategies and alternatively non-pharmacologic strategies have been demonstrated to further diminish its occurrence. The objective of this manuscript is to provide a comprehensive review of anesthetic considerations for pediatric ED and to provide an update on techniques that have been found to be effective in reducing the overall risk of developing postoperative ED in pediatric patients.

Pre-medication before dental procedures: A randomized controlled study comparing intranasal dexmedetomidine with oral midazolam

BACKGROUND

This study aimed to determine if intranasal dexmedetomidine is a superior pre-medication to oral midazolam in older, difficult children.

METHODS

This was conducted as a prospective, single-blind randomized control trial in a tertiary care center. Seventy-five children, age >5 years and weight >20 kg, who needed general anesthesia for dental procedures were randomly assigned to be pre-medicated with either oral midazolam at a dose of 0.5 mg/kg (max 15 mg) or intranasal dexmedetomidine at a dose of 2 mcg/kg (max 100 mcg). The primary outcome studied was the patients' level of sedation when separated from their parents, which was assessed using a 5-point University of Michigan Sedation Scale. Secondary outcome studied was the level of anxiolysis assessed by the acceptance of mask induction using a 4-point scale. All assessments were made by one research person blinded to the study drug.

RESULTS

The two groups were similar in age, sex, weight, pre-anesthetic behavior, time from pre-medication to anesthesia induction, and surgical time. A significantly higher proportion of patients who received dexmedetomidine had satisfactory sedation at separation from parents (69.4% vs 40.5%, P = .03) compared to those who received midazolam. There were no significant differences in the rate of acceptance of mask induction (80.6% vs 78.4%, P = 1.00). Intranasal dexmedetomidine was tolerated well when administered using a mucosal atomizer and without any clinically significant effect on heart rate or systolic blood pressure.

CONCLUSIONS

Intranasal dexmedetomidine provides higher success rate in sedation and parental separation compared to oral midazolam, in older, difficult children.

Optimal Dexmedetomidine Dose to Prevent Emergence Agitation Under Sevoflurane and Remifentanil Anesthesia During Pediatric Tonsillectomy and Adenoidectomy

Background: Emergence agitation (EA) is a common pediatric complication after sevoflurane anesthesia that can be prevented with dexmedetomidine. However, an inappropriate dose of dexmedetomidine can cause prolonged sedation and cardiovascular complications. Thus, we evaluated the optimal dose (ED95) of dexmedetomidine for preventing EA with sevoflurane and remifentanil anesthesia after pediatric tonsillectomy and adenoidectomy.

Methods: We enrolled American Society of Anesthesiologists (ASA) I and II children 3–7 years of age who underwent tonsillectomy with adenoidectomy. During induction, dexmedetomidine was infused for 10 min. Anesthesia was induced with sevoflurane and maintained with sevoflurane and remifentanil, resulting in a bispectral spectrum index (BIS) range from 40 to 60. Extubation time, surgical and anesthetic duration time, and duration time in the postanesthesia care unit (PACU) stay were recorded. EA [measured with Pediatric Anaesthesia Emergence Delirium (PAED) scores] and pain [measured with Face, Legs, Activity, Cry, Consolability (FLACC) scores] were assessed at extubation (E0), 15 min after extubation (E1), and 30 min after extubation (E2). If EA occurred, the next surgical procedure included increased dexmedetomidine by 0.1 μg/kg, and if not, the drug was reduced by 0.1 μg/kg.

Results: The 50% effective dose (ED50) of dexmedetomidine for preventing EA after sevoflurane and remifentanil anesthesia for tonsillectomy and adenoidectomy was 0.13 μg/kg, and its 95% confidence interval is 0.09–0.19 μg/kg; ED95 was 0.30 μg/kg, and its 95% confidence interval is 0.21–1.00 μg/kg.

Conclusion: Intravenous dexmedetomidine infusion at ED50 (0.13 μg/kg) or ED95 (0.30 μg/kg) during induction for 10 min can prevent half or almost all EA after sevoflurane and remifentanil anesthesia during pediatric tonsillectomy and adenoidectomy.

Effect of ancillary drugs on sevoflurane related emergence agitation in children undergoing ophthalmic surgery: a Bayesian network meta-analysis

BACKGROUND

The comparative efficacy of ancillary drugs on sevoflurane related emergence agitation (EA) in children undergoing ophthalmic surgery remains controversial.

METHODS

The databases were retrieved in an orderly manner from the dates of their establishment to October, 2018, including PubMed, The Cochrane Library and Web of Science, to collect randomized controlled trials (RCT) of different anesthetic drugs combined with sevoflurane for ophthalmic surgery. Then a network meta-analysis was conducted using R and Stata 12.0 softwares.

RESULTS

The meta-analysis showed that, in reducing sevoflurane related EA, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil and clonidine were superior to placebo (P < 0.05). The network meta-analysis showed that the effects of ancillary drugs combine with sevoflurane in reducing risk of EA in children undergoing ophthalmic surgery was superior to placebo: dexmedetomidine (OR = 0.17, 95% CrI 0.12-0.22), ketamine (OR = 0.30, 95% CrI 0.11-0.49), propofol (OR = 0.24, 95% CrI 0.09-0.63), fentanyl (OR = 0.16, 95% CrI 0.08-0.56), midazolam (OR = 0.20, 95% CrI 0.09-0.40), sufentanil (OR = 0.27, 95% CrI 0.14-0.41), remifentanil (OR = 0.18, 95% CrI 0.08-0.54) and clonidine (OR = 0.14, 95% CrI 0.07-0.41). The SUCRA of placebo, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil, clonidine were respectively 0.26, 77.93, 27.71, 42.8, 69.43, 52.89, 59.83, 57.62 and 61.53%.

CONCLUSIONS

The effects of dexmedetomidine combine with sevoflurane in reducing risk of emergence agitation in children undergoing ophthalmic surgery was superior to other drugs.

Effect of Single-Dose Dexmedetomidine on Intraoperative Hemodynamics and Postoperative Recovery during Pediatric Adenotonsillectomy

Background

In children undergoing adenotonsillectomy, smooth recovery from anesthesia without any respiratory compromise and excessive sedation or pain is always desirable. In this placebo-controlled study, we examined the effect of single dose of dexmedetomidine on intraoperative hemodynamics and postoperative recovery profile such as emergence agitation (EA), pain, and sedation in children undergoing adenotonsillectomy.

Methods

Sixty American Society of Anesthesiologists I or II children in the age group of 5-10 years, undergoing adenotonsillectomy were randomly assigned to receive dexmedetomidine 1 μg/kg (Group D) or volume-matched saline (placebo) (Group C), 10 min before induction of anesthesia. Intraoperative heart rate (HR) and mean blood pressure (MBP), duration of surgery, time to extubation, EA using Paediatric Anaesthesia Emergence Delirium (PAED) scale, level of sedation in postanesthesia care unit using Ramsay sedation score (RSS), and postoperative visual analog score (VAS) for pain were recorded and compared.

Results

Dexmedetomidine group had lower HR and stable MBP, compared to the control group (P < 0.05). Postoperatively, the agitation score (PAED scale score) was statistically lower in Group D compared to Group C (13.84 ± 1.39; median 14 in Group C vs. 9.37 ± 1.33; median 9.5 in Group D; P < 0.001). All patients in Group C had PAED scale score >12, while only 6.67% of patients in Group D had PAED scale score of 12. The patients in Group D had higher RSS (2.62 ± 0.49 in Group D vs. 1.60 ± 0.50, P = 0.004); none of the patients were excessively sedated or had RSS >3. No significant difference was found in VAS score of the groups at all times, except at 0 h (P = 0.002). Time to extubation was significantly longer in the dexmedetomidine group (7.70 ± 1.62 min in Group D vs. 5.23 ± 1.91 min in Group C; P = 0.001).

Conclusion

Premedication of dexmedetomidine at the dose of 1 μg/kg in children undergoing adenotonsillectomy resulted in favorable effect on intraoperative hemodynamics, significant decrease in postoperative EA without causing any excessive sedation, desaturation, or any other drug-related adverse events.

Effects of different doses of intranasal dexmedetomidine on preoperative sedation and postoperative agitation in pediatric with total intravenous anesthesia undergoing adenoidectomy with or without tonsillectomy

Dexmedetomidine is a highly selective α2 receptor agonist, this study aimed to investigate the effects of different doses of intranasal dexmedetomidine on the preoperative sedation and postoperative agitation in pediatric with total intravenous anesthesia (TIVA) for adenoidectomy with or without tonsillectomy.This is a double-blind placebo-controlled randomized trial. Pediatric were randomly divided into the D1, D2, and S groups, each group contained 30 patients. Twenty-five to 40 minutes before surgery, the D1 and D2 groups received intranasally dexmedetomidine 1 μg kg or 2 μg kg, respectively, while the S group received saline of the same volume. A unified protocol of TIVA induction and maintenance was used for the three groups. The preoperative sedation, behavior of separation from parents, postoperative agitation, and postoperative pain of the children were evaluated.The proportions of satisfactory sedation in the D1, D2, and S groups were 63.3%, 76.7%, and 0%, respectively. There was a statistically significant difference between D1 and S groups (P = .000) and D2 versus S groups (P = .000), while there was no statistically significant difference between D1 and D2 groups (P = .399). As for scale on the behavior of separation from parents, there was a statistically significant difference between D1 and S groups (P = .009) and D2 versus S groups (P = .009), whereas there was no significant difference between D1 and D2 groups (P = 1). The incidence of postoperative agitation in the D1, D2, and S groups was 43.3%, 30.0%, and 63.3%, respectively, and there was a statistical difference between D2 and S groups (P = .010). There was a significant difference in the Pediatric Anesthesia Emergence Delirium (PAED) scale between D2 and S groups (P = .029). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) in the D2 group was significantly lower than the S group (P = .013).The intranasal dexmedetomidine of 1 or 2 μg kg 25 to 40 minute before induction of anesthesia both could deliver effective preoperative sedation, reducing the children's distress of separation from parents. Moreover, intranasal dexmedetomidine of 2 μg kg could deliver more effective postoperative analgesia and reduce postoperative agitation, without prolonging postoperative recovery or causing severe adverse events.

Visual preconditioning reduces emergence delirium in children undergoing ophthalmic surgery: a randomised controlled trial

BACKGROUND

Emergence delirium is a common complication in children, especially in preschool children undergoing ophthalmic surgery. The aim of the study was to investigate the effects of visual preconditioning (application of an eyepatch over the eye to be operated for ≥3 h the day before surgery) on emergence delirium after ophthalmic surgery under sevoflurane anaesthesia.

METHODS

One hundred and seventy-nine children undergoing unilateral cataract surgery, aged 3-7 yr, were involved in this prospective, blinded, randomised study. Subjects were randomised to receive visual preconditioning (Group P, n=89) or to receive programmed explanation the day before surgery (Group C, n=90). The primary outcome was incidence of emergence delirium evaluated by the paediatric anaesthesia emergence delirium (PAED) scale. The secondary outcomes included emergence time and post-anaesthesia care unit (PACU) stay time.

RESULTS

Children in Group P had a significantly lower incidence of emergence delirium than those in Group C [16.9% vs 44.4%, odds ratio (OR) 4.0, 95% confidence interval (CI) 2.0 to 8.0]. The maximal PAED score was lower in Group P than in Group C [4 (0-20) vs 9 (0-20), median difference -3.0, 95% CI -5.0 to -1.0]. Visual preconditioning prolonged emergence time (P<0.001) and PACU stay time (P=0.002).

CONCLUSION

Visual disturbance contributes to emergence delirium in preschool children undergoing ophthalmic surgery with sevoflurane, and prophylactic eyepatch treatment can reduce emergence delirium.

CLINICAL TRIALS REGISTRATION

NCT02590744.