Comparison between dexmedetomidine and midazolam premedication in pediatric patients undergoing ophthalmic day-care surgeries

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.

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.

A comparative evaluation of dexmedetomidine and midazolam in pediatric sedation: A meta-analysis of randomized controlled trials with trial sequential analysis

Background

The present study with trial sequential analysis (TSA) was conducted to evaluate comprehensively the efficacy and safety of dexmedetomidine and midazolam in pediatric sedation, and to investigate whether the outcomes achieved the required information size to draw the conclusions.

Methods

PubMed, Embase, and Cochrane Library were searched from inception to October 2019. All randomized controlled trials used dexmedetomidine and midazolam in pediatric sedation were enrolled. Sedative efficacy, postoperative analgesic effect, and incidence of emergence agitation were considered as the co‐primary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to rate the quality of evidences.

Results

We acquired data from 34 studies involving 2281 pediatric patients. The results indicated that administration of dexmedetomidine was associated with less incidence of emergence agitation (RR = 0.78, with 95% CI [0.65, 0.92]) and more satisfactory sedation at parental separation (RR = 0.31, with 95% CI [0.24, 0.41]) compared to midazolam, and the current sample sizes were sufficient with unnecessary further trials. Two groups did not differ significantly in sedation level at mask induction (RR = 0.86, with 95% CI [0.74, 1.00]). And using of dexmedetomidine was associated with less incidence of postoperative analgesic rescue (RR = 0.57, with 95% CI [0.35, 0.93]), but the number of patients was too few to achieve the required information size and to draw reliable conclusions. Premedication of dexmedetomidine was associated with significant less value of SBP, heart rate, increased incidence of bradycardia, and a lower rate of shivering. And there were no differences about onset of sedation and recovery time between two groups.

Conclusions

Given that more satisfactory sedation at separation from parents and less incidence of emergence agitation, dexmedetomidine is preferred for pediatric sedation. However, compared with midazolam, the superiority of dexmedetomidine in providing adequate sedation at mask induction and postoperative analgesic effects has not yet been defined.

Effects of Dexmedetomidine on Emergence Agitation and Recovery Quality Among Children Undergoing Surgery Under General Anesthesia: A Meta-Analysis of Randomized Controlled Trials

Background: Emergence agitation (EA) is one of the most common and intractable postoperative complications among children undergoing surgery under general anesthesia. Dexmedetomidine, an α(2)-adrenoceptor agonist, offers an ideal sedation, reduces preoperative anxiety, and facilitates smooth induction of anesthesia, and it is widely used in pediatric surgery. We aimed to evaluate the efficacy of dexmedetomidine for preventing emergence agitation in children after general anesthesia. Methods: We comprehensively reviewed PubMed, Cochrane Library, EMBASE, and Web of Science databases to search all randomized controlled trials, published before April 22, 2020, investigating the efficacy of dexmedetomidine in preventing the emergence agitation in children after general anesthesia. The meta-analysis was performed using Review Manager 5.3. The primary outcome was the incidence of emergence agitation. Secondary outcomes included the number of patients requiring rescue analgesic, number of patients with postoperative nausea and vomiting, emergence time, extubation time, and time to discharge from the post-anesthesia care unit. Results: We included a total of 33 studies, comprising 2,549 patients in this meta-analysis. Compared with saline, dexmedetomidine significantly reduced the emergence agitation incidence [risk ratio (RR) 0.29; 95% confidence interval (CI) 0.22-0.37; p < 0.00001], incidence of postoperative nausea and vomiting (RR 0.46; 95% CI 0.3-0.69; p = 0.0002), and the requirement of rescue analgesic (RR 0.29; 95% CI 0.18-0.44; p < 0.00001). Furthermore, children in the dexmedetomidine group experienced a longer emergence time [mean difference (MD) 2.18; 95% CI 0.81-3.56; p = 0.002] and extubation time (MD 0.77; 95% CI 0.22-1.31; p = 0.006) compared with those in the saline group. However, no significant difference was observed in the time to discharge from the post-anesthesia care unit (MD 2.22; 95% CI -2.29-6.74; p = 0.33) between the two groups. No significant differences were observed between the effects of dexmedetomidine and other drugs like midazolam, propofol, fentanyl, tramadol, and clonidine in terms of the emergence agitation incidence and other parameters, except for the requirement of rescue analgesic (RR 0.45; 95% CI 0.33-0.61; p < 0.00001). Conclusions: Dexmedetomidine can prevent emergence agitation, relieves postoperative pain, decreases the requirement of rescue analgesic, and decreases the postoperative nausea and vomiting events.

Comparison of single minimum dose administration of dexmedetomidine and midazolam for prevention of emergence delirium in children: a randomized controlled trial

PURPOSE

Emergence delirium (ED) is common in children after sevoflurane anesthesia and should be prevented for patient safety. A prospective, double-blind, randomized, controlled study was performed to compare the efficacy of minimal dosage of midazolam versus dexmedetomidine to prevent ED in children undergoing tonsillectomy.

METHODS

Seventy children aged 24 months to 12 years were allocated to receive midazolam (0.03 mg/kg) or dexmedetomidine (0.3 µg/kg) 5 min before the end of surgery. The incidence and severity of ED were assessed using a four-point scale and the pediatric anesthesia emergence delirium scale, respectively. The emergence time and postoperative pain scores were also evaluated.

RESULTS

The incidence of ED was 31.3% in the midazolam group and 26.5% in the dexmedetomidine group (P = 0.668). The severity of ED was similar in both groups (9.6 ± 5.8 in the midazolam group, vs. 8.1 ± 5.9 in the dexmedetomidine group, P = 0.299). The emergence time was comparable in the two groups [11.0 (8.3-13.8) min in midazolam group vs. 12.0 (10.0-13.5) min in dexmedetomidine group (P = 0.218)]. Postoperative pain score was higher in the midazolam group [0 (0-1)] than in the dexmedetomidine group [0 (0-0)] (P = 0.011).

CONCLUSION

Dexmedetomidine and midazolam at single minimum dosages had equal effectiveness to prevent ED in children without delaying emergence time, when administered at the end of surgery. With regards to postoperative analgesic efficacy, although dexmedetomidine showed statistically significant higher analgesic effect than midazolam, further clinical investigations are needed to validate our findings.

Perioperative considerations and anesthesia management in patients with obstructive sleep apnea undergoing ophthalmic surgery

Obstructive sleep apnea (OSA) is a disorder characterized by breathing cessation caused by obstruction of the upper airway during sleep. It is associated with multiorgan comorbidities such as obesity, hypertension, heart failure, arrhythmias, diabetes mellitus, and stroke. Patients with OSA have an increased prevalence of ophthalmic disorders such as cataract, glaucoma, central serous retinopathy (detachment of retina, macular hole), eyelid laxity, keratoconus, and nonarteritic anterior ischemic optic neuropathy; and some might require surgery. Given that OSA is associated with a high incidence of perioperative complications and more than 80% of surgical patients with OSA are unrecognized, all surgical patients should be screened for OSA (eg, STOP-Bang questionnaire) with comorbidities identified. Patients suspected or diagnosed with OSA scheduled for ophthalmic surgery should have their comorbid conditions optimized. This article includes a review of the literature and highlights best perioperative anesthesia practices in the management of ophthalmic surgical patients with OSA.

Intravenous dexmedetomidine pre-medication reduces the required minimum alveolar concentration of sevoflurane for smooth tracheal extubation in anesthetized children: a randomized clinical trial

Background

It has been known that Dexmedetomidine pre-medication enhances the effects of volatile anesthetics, reduces the need of sevoflurane, and facilitates smooth extubation in anesthetized children. This present study was designed to determine the effects of different doses of intravenous dexmedetomidine pre-medication on minimum alveolar concentration of sevoflurane for smooth tracheal extubation (MAC_EX) in anesthetized children.

Methods

A total of seventy-five pediatric patients, aged 3–7 years, ASA physical status I and II, and undergoing tonsillectomy were randomized to receive intravenous saline (Group D₀), dexmedetomidine 1 μg∙kg⁻¹ (Group D₁), or dexmedetomidine 2 μg∙kg⁻¹ (Group D₂) approximately 10 min before anesthesia start. Sevoflurane was used for anesthesia induction and anesthesia maintenance. At the end of surgery, the initial concentration of sevoflurane for smooth tracheal extubation was determined according to the modified Dixon’s “up-and-down” method. The starting sevoflurane for the first patient was 1.5% in Group D₀, 1.0% in Group D₁, and 0.8% in Group D₂, with subsequent 0.1% up or down in next patient based on whether smooth extubation had been achieved or not in current patient. The endotreacheal tube was removed after the predetermined concentration had been maintained constant for ten minutes. All responses (“smooth” or “not smooth”) to tracheal extubation and respiratory complications were assessed.

Results

MAC_EX values of sevoflurane in Group D₂ (0.51 ± 0.13%) was significantly lower than in Group D₁ (0.83 ± 0.10%; P < 0.001), the latter being significantly lower than in Group D₀ (1.40 ± 0.12%; P < 0.001). EC₉₅ values of sevoflurane were 0.83%, 1.07%, and 1.73% in Group D₂, Group D₁, and Group D₀, respectively. No patient in the current study had laryngospasm.

Conclusion

Dexmedetomidine decreased the required MAC_EX values of sevoflurane to achieve smooth extubation in a dose-dependent manner. Intravenous dexmedetomidine 1 μg∙kg⁻¹ and 2 μg∙kg⁻¹ pre-medication decreased MAC_EX by 41% and 64%, respectively.

Trial registration

Chinese Clinical Trial Registry (ChiCTR): ChiCTR-IOD-17011601, date of registration: 09 Jun 2017, retrospectively registered.

Therapeutic Efficacy of Two Different Doses of Dexmedetomidine on the Hemodynamic Response to Intubation, the Intubating Conditions, and the Effect on the Induction Dose of Propofol: A Randomized, Double-Blind, Placebo-Controlled Study

Context:

The hemodynamic response associated with laryngoscopy and tracheal intubation is a common concern for the anesthesiologist, especially in high-risk patients. The use of dexmedetomidine has found favor in obtunding this response, in addition to providing better intubating conditions and reducing the dose of other anesthetic drugs. Most of the current literature states a loading dose of 1 μg/kg dexmedetomidine to be superior to lower doses in this regard. However, using a lower dose may be advantageous by reducing incidence of adverse effects such as hypotension and bradycardia which are likelier with the use of higher dose, in addition to being more cost-effective.

Aims:

The aim of the study was (1) to evaluate and compare the effect of loading doses of 1 μg/kg and 0.5 μg/kg dexmedetomidine on attenuation of hemodynamic response to laryngoscopy and intubation and (2) to evaluate the efficacy of dexmedetomidine in reducing the induction dose of propofol for achieving better intubating conditions.

Materials and Methods:

A randomized, double-blind, placebo-controlled study was planned on ninety American Society of Anesthesiologists I and II patients scheduled for elective surgery under general anesthesia. Patients were divided into three groups. Two groups received different loading doses of dexmedetomidine infusion before induction and the third group was a control group. The induction dose of propofol required to abolish the verbal response was noted and compared in all the three groups. All patients were assessed for the intubating conditions and hemodynamic response.

Statistical Analysis:

Nonparametric data were compared using the Chi-square test and parametric data were compared using Student's t-test using SPSS 16.0 software.

Results:

Both the loading doses of 1 μg/kg and 0.5 μg/kg dexmedetomidine were equally effective in reducing the induction dose of propofol, improving the intubating conditions and blunting the hemodynamic response to laryngoscopy and intubation. The incidence of adverse effects such as hypotension and bradycardia was lesser with the loading dose of 0.5 μg/kg.

Conclusions:

Dexmedetomidine when used as infusion in the loading dose of 0.5 μg/kg is therapeutically as effective as when used in the dose of 1.0 μg/kg not only in reducing the induction dose of propofol but also in providing good intubating conditions and blunting the hemodynamic response to intubation. A lower dose is associated with a lesser incidence of adverse effects such as hypotension and bradycardia.

Randomized comparison between dexmedetomidine and midazolam for prevention of emergence agitation after nasal surgeries

Background

Emergence agitation (EA) in nasal surgeries is seen in around 22% of patients, which can go to dangerous levels. Dexmedetomidine is effective in prevention of EA in such patients. Midazolam given as premedication fails to prevent EA due to its short half-life. In this study, we compared efficacy of dexmedetomidine and midazolam by intravenous infusion for prevention of EA in adult nasal surgeries.

Materials and Methods

Seventy patients belonging to American society of anesthesiologist Status I and II, between 18 and 60 years of age posted for elective nasal surgeries were randomly divided into two groups. Group D received intravenous dexmedetomidine 0.5 mcg/kg over 15 min followed by 0.1 mcg/kg/h. Group M received intravenous midazolam 0.02 mg/kg over 15 min followed by 0.02 mg/kg/h. EA scores, emergence times, and hemodynamic parameters were monitored and compared between the groups. Statistical analysis was done by independent t-test, Mann-Whitney U-test, and Chi-square test as applicable.

Results

Incidence of EA was comparable between the groups (P = 0.23). Two patients in midazolam group developed dangerous agitation while none in dexmedetomidine group. Patients in midazolam group (12.4%) were agitated even in postoperative period, which was not seen with dexmedetomidine group. Hypotension and bradycardia were seen more in dexmedetomidine group.

Conclusion

Efficacy of midazolam when given as an intravenous infusion is comparable to dexmedetomidine in prevention of EA in nasal surgeries.

Tracheal extubation in deeply anesthetized pediatric patients after tonsillectomy: a comparison of high-concentration sevoflurane alone and low-concentration sevoflurane in combination with dexmedetomidine pre-medication

BACKGROUND

Dexmedetomidine can facilitate a smooth extubation process and reduce the requirement of sevoflurane and emergence agitation when administrated perioperatively. We aimed to observe the extubation process and the recovery characteristics in pediatric patients undergoing tonsillectomy while anesthetized with either high-concentration sevoflurane alone or low-concentration sevoflurane combined with pre-medication of single dose of intravenous dexmedetomidine.

METHODS

Seventy-five patients (ASA I or II, aged 3-7 years) undergoing tonsillectomy were randomized into three equal groups: to receive intravenous saline (Group D0), dexmedetomidine 1 μg/kg (Group D1), or dexmedetomidine 2 μg/kg (Group D2) approximately 10 min before anesthesia. Before the end of surgery, sevoflurane were adjusted to 1.5 times, 1.0 time and 0.8 times the minimal effective concentration in groups D₀, D₁ and D₂, respectively. The sevoflurane concentration for each group was maintained for at least 10 min before the tracheal deep-extubation was performed. The extubation event, recovery characteristics and post-op respiratory complications were recorded.

RESULTS

All tracheal tubes in three groups were removed successfully during deep anesthesia. Nine patients in Group D₀, three patients in Group D₁, and two patients in Group D₂ required oral airway to maintain a patent airway after extubation. The frequency of oral airway usage in groups D₁ and D₂ were significantly lower than that in Group D₀. The percentages of patients with ED and the requirements of fentanyl in groups D₁ and D₂ were also significantly lower than those in Group D₀. The time from extubation to spontaneous eye opening in Group D₂ was longer than that in groups D₀ and D₁. The times of post-anesthesia care unit discharge in groups D₀ and D₂ were longer than that in Group D₁. No other respiratory complications and vomiting were observed.

CONCLUSION

A single dose of intravenous dexmedetomidine as pre-medication in combination with low-concentration sevoflurane at the end of surgery provided safe and smooth deep extubation condition and it also lowered the emergence agitation in sevoflurane-anaesthetized children undergoing tonsillectomy. Preoperative dexmedetomidine at 1 μg/kg did not prolong postoperative recovery time.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR): ChiCTR-IOR-16008423 , date of registration: 06 may 2016.

Is dexmedetomidine superior to midazolam as a premedication in children? A meta-analysis of randomized controlled trials

BACKGROUND

In the current published literature, there are controversial results regarding the effectiveness of dexmedetomidine compared with midazolam as premedication in children. The aim of this meta-analysis was to compare the use of dexmedetomidine as a premedication in pediatric patients with that of midazolam.

METHODS

We searched for articles published in English that matched the key words 'dexmedetomidine', 'midazolam', and 'children' in the PubMed, Cochrane Library, Ovid, and Google Scholar databases. Additional studies were identified from the reference lists of the retrieved articles. Only prospective randomized controlled trials (RCTs) that compared the use of dexmedetomidine and midazolam as premedications in children were included. The extraction of data from the articles was performed independently by two authors using a predesigned Excel spreadsheet. The relative risks (RRs), weighted mean differences (WMDs), and their corresponding 95% confidence intervals (95% CIs) were calculated for dichotomous and continuous outcome data using the quality effects model of the MetaXL version 1.3 software.

RESULTS

Eleven prospective RCTs (829 children) met our criteria. Compared with midazolam, dexmedetomidine premedication was associated with more satisfactory sedation upon parent separation (eight RCTs [679 children]; RR: 1.25; 95% CI: 1.06, 1.46) and upon mask acceptance (seven RCTs [559 children]; RR: 1.17; 95% CI: 1.01, 1.36). During the postoperative period, premedication with dexmedetomidine lowered the numbers of requests for rescue analgesia (six RCTs [477 children]; RR: 0.55; 95% CI: 0.40, 0.74) and lowered the risks of agitation or delirium (seven RCTs with [466 children]; RR: 0.59; 95% CI: 0.40, 0.88), and shivering (three RCTs [192 children]; RR: 0.33; 95% CI: 0.18, 0.61). However, dexmedetomidine premedication reduced systolic blood pressure (three RCTs [242 children]; WMD: -11.47 mm·Hg(-1) ; 95% CI: -13.95, -8.98), mean blood pressure (three RCTs [202 children]; WMD: -5.66 mm·Hg(-1) ; 95% CI: -8.89, -2.43), and heart rate (six RCTs [444 children]; WMD: -12.71 beat·min(-1) ; 95% CI: -14.80, -10.62), and prolonged the onset of sedation (two RCTs [132 children] WMD: 13.78 min; 95% CI: 11.33, 16.23; I(2) = 0%) relative to midazolam.

CONCLUSION

This meta-analysis demonstrated that dexmedetomidine premedication is superior to midazolam premedication in terms of producing satisfactory sedation upon parent separation and mask acceptance. Dexmedetomidine premedication provides clinical benefits that included reducing the requirements for rescue analgesia and reducing agitation or delirium and shivering during the postoperative period. However, the risks of heart rate and blood pressure decreases, and the prolonged onset of sedation associated with dexmedetomidine should be considered.