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

Determination of the ED90 of Dexmedetomidine Infusion to Prevent Emergence Agitation in Children Undergoing Dental Rehabilitation With Sevoflurane Anesthesia: A Biased-Coin Up-and-Down Sequential Allocation Trial

BACKGROUND

Emergence agitation (EA) is an adverse complication during early recovery from sevoflurane anesthesia. Continuous intravenous infusion of dexmedetomidine (DEX) is commonly used for EA prevention. However, a wide dose range is used for preventing EA, and the optimal dose remains unknown. This study was aimed at determining the optimal dose (the 90% effective dose [ED90]) of DEX for continuous intraoperative infusion for EA prevention in children.

METHODS

We enrolled children aged 3 to 7 years who underwent dental treatment under sevoflurane anesthesia. DEX was continuously infused from the time of the establishment of the intravenous access until 5 minutes before the end of surgery. The initial DEX dose was 0.5 µg/kg/h, and subsequent dose adjustments were determined based on the response of the previous patient by using an up-down sequential allocation with a biased-coin design. The primary outcome was the ED90 for continuous DEX infusion based on the success or failure of the EA-preventing dose.

RESULTS

Forty-five patients were enrolled in the study. The DEX dose ranged from 0.50 to 0.90 µg/kg/h. The estimated ED90 (95% confidence interval [CI]) for preventing EA was 0.74 µg/kg/h (0.67-1.05 µg/kg/h). The duration of surgery (mean ± standard deviation [SD]) was 113 ± 30 minutes. The times (mean ± SD) for extubation, time to emergence, and recovery time were 5 ± 2 minutes, 27 ± 9 minutes, and 39 ± 7 minutes, respectively.

CONCLUSIONS

The ED90 for continuous intraoperative DEX infusion for EA prevention in pediatric patients receiving dental treatment under sevoflurane anesthesia was 0.74 µg/kg/h (95% CI, 0.67-1.05 µg/kg/h).

Investigating the Effect of Dexmedetomidine in Controlling Postoperative Emergence Agitation in Children under Sevoflurane Anesthesia

Introduction

Emergence agitation (EA) is one of the common problems during recovery from general anesthesia, especially in children. In this study, we investigated the effect of dexmedetomidine on the control of agitation after anesthesia with sevoflurane in children.

Method

This randomized control-placebo, double-blind prospective clinical trial was conducted on seventy-six children between 2 and 7 years with ASA (American Society of Anesthesiologists) class I who were candidates for elective adenoidectomy surgery and tonsillectomy. Participants were selected by an available sampling method. Patients were randomly placed in one of the two groups D (dexmedetomidine 0.5 μg/kg infusion within ten minutes) or P (placebo: normal saline infusion within ten minutes). A four-point scale evaluated agitation. Pain evaluation was done by FLACC (faces, legs, activity, cry, and consolability). The statistical software was SPSS version 23. P < 0.05 was considered statistically significant.

Results

The level of agitation was significantly lower in the intervention group (P < 0.05), except after 40 minutes in the PACU (Post Anesthesia Care Unit) (P=1.00). Patients in the control group experienced high pain scores when admitted at PACU, 10, 20, and 30 minutes after admission at PACU (P < 0.05). Pethidine and metoclopramide prescriptions in the intervention group were lower than in the control group (P < 0.05). Shivering occurred in five patients in the intervention group and nine in the control groups (P=0.032). Hypotension that required intervention occurred in 3 patients in the intervention group and one in the control group (P=0.024).

Conclusion

Our trial demonstrated that the prescription of 0.5 μg/kg of dexmedetomidine within ten minutes after intubation significantly reduced the EA frequency, pain severity, analgesic consumption, and PONV (postoperative nausea and vomiting). However, it caused delays in the emergence from anesthesia. This trial is registered with IRCT20160430027677N14.

Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series

BACKGROUND

Surgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthesia. These complications are detrimental to the child and medical personnel and cause tremendous psychologic stress to parents. Our aim is to decrease these complications through dexmedetomidine, an alpha-2 receptor agonist with anxiolytic, sympatholytic, and analgetic properties. Devoid of respiratory depressant effect, it allows patients to maintain effective ventilation and reduce agitation, postoperatively. Its unique anesthetic property may shed light on providing safe anesthesia and gentle emergence to this young, vulnerable population.

CASE PRESENTATION

A total of 21 patients of Sundanese ethnicity, aged 3 months to 8 years (9 males and 12 females), underwent cleft lip or cleft palate surgery using total intravenous dexmedetomidine. Anesthesia was induced using sevoflurane, fentanyl, and propofol, and airway was secured. Intravenous dexmedetomidine 1.5 μg/kg was administered within 10 minutes, and a maintenance dose of 1.5 μg/kg/hour was continued as the sole anesthetic maintenance agent thereafter. Hemodynamics and anesthetic depth using Patient State Index (SEDLine™ monitor, Masimo Corporation, Irvine, CA, USA) were monitored carefully throughout the surgical procedure. Dexmedetomidine did not cause any hemodynamic derangements or postoperative complications in any of our patients. We found agitation in 9.5% (2/21) of patients.

CONCLUSION

Dexmedetomidine can be used as a total intravenous anesthetic agent to maintain anesthesia and provide gentle emergence to infants and young children undergoing cleft lip and palate repair.

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.

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.

Improved postoperative recovery profile in pediatric oral rehabilitation with low-dose dexmedetomidine as an opioid substitute for general anesthesia: a randomized double-blind clinical trial

Background

Low-dose dexmedetomidine may be a suitable alternative to opioids for pediatric ambulatory procedures under general anesthesia (GA). However, the recovery profile remains unclear. Herein, we aimed to evaluate the effects of low-dose dexmedetomidine on the recovery profile of children.

Methods

Seventy-two children undergoing ambulatory oral rehabilitation under GA were randomly and equally distributed into two groups (D and F). Group D received an infusion of dexmedetomidine 0.25 µg/kg for 4 min for induction, followed by maintenance of 0.4 µg/kg/h. Group F received an infusion of fentanyl 1 µg/kg over 4 min for induction, followed by maintenance at 1 µg/kg/h. The primary outcome was the extubation time. The secondary outcomes were awakening time, end-tidal sevoflurane (ET-Sevo) requirement, change in hemodynamic parameters, Richmond Agitation-Sedation Scale (RASS), Children's Hospital of Eastern Ontario pain scale (CHEOPS) score, length of PACU stay, and incidence of adverse events.

Results

Statistically significant differences were observed in the recovery profile between the groups: the median time for extubation was 3.65 (3.44-6.2) vs. 6.25 (4.21-7) minutes in groups D vs. F (P = 0.001), respectively, while the corresponding awakening times were 19 (18.75-21) and 22.5 (22-24) minutes, respectively (P < 0.001). The mean ET-Sevo was low in group D (1.1 vs. 1.2; P < 0.001). The heart rate was significantly low across all time points in group D, without resulting in bradycardia. The median RASS and CHEOPS scores were also significantly lower in group D. No significant differences were observed in the mean arterial pressure, incidence of adverse events, or length of PACU stay.

Conclusion

Low-dose dexmedetomidine was more effective than fentanyl as an opioid substitute at providing a better recovery profile in pediatric ambulatory oral rehabilitation under GA. Dexmedetomidine also significantly reduced sevoflurane consumption without causing adverse events or prolonging hospital stay.

Dexmedetomidine infusion for emergence coughing prevention in patients undergoing an endovascular interventional procedure: A randomized dose-finding trial

OBJECTIVE

Dexmedetomidine has been introduced in emergence coughing, agitation, and shivering prevention. This study aimed to investigate the optimal dose of dexmedetomidine for emergence cough prophylaxis.

METHODS

In this randomized, double-blinded, and prospective trial, 356 patients scheduled for an endovascular interventional procedure were randomly assigned to 0.3 (D 0.3), 0.4 (D 0.4), 0.5 (D 0.5), and 0.6 (D 0.6) μg·kg^-1·h^-1 dexmedetomidine rate, or saline control (C), from anesthesia induction until the end of surgery. The primary outcomes measured were cough grade and frequency. Additionally, groups were compared according to mean arterial pressure (MAP), heart rate, agitation, shivering, postoperative nausea and vomiting (PONV), extubation time, sedation scores, and postoperative first night sleep quality (secondary outcomes).

RESULTS

A total of 351 patients were included in the analysis. The respective incidences of D 0.3, D 0.4, and D 0.5 versus C group were: 78.6%, 68.6%, 53.4% and 42.9% vs 89.7% for cough (p = 0.002, p < 0.001, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 30%, 27.1%, 20.5%, 15.7% vs 44.1% for agitation (p = 0.04, p = 0.003, and p < 0.001 between group D 0.4, D 0.5 and D 0.6 vs C, respectively); 8.6%, 7.1%, 6.8%, 5.7% vs 22.1% for shivering (p = 0.027, p = 0.013, p = 0.01, and p = 0.01 between D 0.3, D 0.4, D 0.5 and D 0.6 vs C, respectively); and 52.9%, 57.1%, 42.5%, 44.3% vs 61.8% for poor sleep quality (p = 0.02 and p = 0.04 between group D 0.5 and D 0.6 vs C, respectively). D 0.4, D 0.5 and D 0.6 showed lower MAP during extubation, compared with the C group. Also, D 0.5 and D 0.6 presented a slight delay in extubation (3.1 and 3.3 min longer than C; p = 0.002 and p < 0.001, respectively). Meanwhile, the frequency of atropine, vasopressor administration, PONV and dizziness were similar to the control.

CONCLUSIONS

Both 0.5 and 0.6 μg·kg^-1·h^-1 dexmedetomidine infusion rates effectively mitigated emergence coughing with prolonged extubation time, besides sleep disturbance. D 0.4, D 0.5, and D 0.6 reduced agitation and sustained hemodynamic stability. Finally, the four doses applied were effective in shivering attenuation.

Efficacy of Dexmedetomidine Anesthesia plus Dorsal Penile Nerve Block in Pediatric Circumcision

Objective

To assess the efficacy of dexmedetomidine anesthesia plus dorsal penile nerve block in pediatric circumcision.

Methods

In this retrospective study, 80 children receiving circumcision in our hospital from February 2020 to February 2021 were recruited and assigned via different anesthesia methods at a ratio of 1 : 1 to receive dorsal penile nerve block plus dexmedetomidine anesthesia (combined anesthesia group) or only sevoflurane for total inhalational anesthesia (total anesthesia group). Traditional Chinese medicine (TCM) care was introduced to both groups of patients. Outcome measures included vital signs, operative indices, anesthesia effect, adverse reactions, parent satisfaction, and nursing satisfaction.

Results

There were no significant differences in the heart rate, oxygen saturation, and mean arterial pressure between the two groups of children before anesthesia, after anesthesia, and during the awakening period (P > 0.05). Patients receiving combined anesthesia showed a shorter time lapse before the disappearance of eyelash reflex, longer time lapse before postoperative analgesic use, faster awakening, and shorter operation time and hospital stay versus those receiving total inhalational anesthesia alone (P > 0.05). The combined anesthesia resulted in a lower Induction Compliance Checklist (ICC) score, McGill score, and Richmond Agitation-Sedation Scale (RASS) score and a higher Ramsay score versus total anesthesia (P > 0.05). Patients receiving combined anesthesia showed a significantly lower incidence of adverse events (5.00% (2/40)) versus total inhalational anesthesia (62.50% (25/40)) (X² = 29.574, P > 0.05). The combined anesthesia group had a higher parent satisfaction (92.50% (37/40)) versus the total anesthesia group (75.00% (30/40)) (X² = 4.501, P > 0.05). A total of 80 questionnaires were distributed, with a 100% return rate and a 100% validity rate, and all 80 questionnaires scored 90 points or above. The families of children in both groups were satisfied with the quality of TCM care.

Conclusion

The efficacy of dorsal penile nerve block plus dexmedetomidine anesthesia in pediatric circumcision is better than total inhalational anesthesia with sevoflurane.