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Wei B, Yu C, Xiao J, Xu H, Zheng P, Wang W. 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. Dose Response 2024; 22:15593258241248919. [PMID: 38645383 PMCID: PMC11032057 DOI: 10.1177/15593258241248919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/06/2024] [Indexed: 04/23/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - JinBo Xiao
- Department of Anesthesiology, The Medical Center of AnQing of Anhui Medical University, AnQing, China
| | - Huang Xu
- Department of Anesthesiology, The Medical Center of AnQing of Anhui Medical University, AnQing, China
| | - Ping Zheng
- Department of Anesthesiology, The Medical Center of AnQing of Anhui Medical University, AnQing, China
| | - WeiBing Wang
- Department of Anesthesiology, The Medical Center of AnQing of Anhui Medical University, AnQing, China
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Na HS, Kim SY, In Park J, Lee S, Hwang JW, Shin HJ. The effect of intranasal dexmedetomidine administration on emergence agitation or delirium in pediatric patients after general anesthesia: A meta-analysis of randomized controlled trials. Paediatr Anaesth 2023. [PMID: 37128675 DOI: 10.1111/pan.14689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/09/2023] [Accepted: 04/11/2023] [Indexed: 05/03/2023]
Abstract
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.
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Affiliation(s)
- Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Su Yeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji In Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sohyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung-Won Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
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Wang W, Zhou H, Sun A, Xiao J, Dong J, Xu H. 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. Dose Response 2021; 19:15593258211037153. [PMID: 34471401 PMCID: PMC8404654 DOI: 10.1177/15593258211037153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/04/2021] [Accepted: 07/09/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- WeiBing Wang
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - Hui Zhou
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - AiJiao Sun
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - JinBo Xiao
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - JingChong Dong
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
| | - Huang Xu
- Department of Anesthesiology, The Affiliated AnQing Municipal Hospitals of Anhui Medical University, AnQing, China
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Intranasal dexmedetomidine premedication in children with recent upper respiratory tract infection undergoing interventional cardiac catheterisation: A randomised controlled trial. Eur J Anaesthesiol 2021; 37:85-90. [PMID: 31644515 DOI: 10.1097/eja.0000000000001097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Recent upper respiratory tract infection (URI) is a risk factor for the occurrence of peri-operative respiratory adverse events (PRAE). This risk may be higher in children with congenital heart disease (CHD), particularly in those undergoing interventional cardiac catheterisation. It is therefore essential to adapt the anaesthetic strategy in these children to prevent from the occurrence of PRAE. OBJECTIVE To determine whether intranasal dexmedetomidine (DEX) premedication can reduce the incidence of PRAE in children with recent URI undergoing interventional cardiac catheterisation. DESIGN Randomised controlled trial. SETTING Single-centre study based at a tertiary care centre in Shanghai, China. PATIENTS A total of 134 children with CHD aged 0 to 16 years with recent URI undergoing interventional cardiac catheterisation. INTERVENTIONS Children were randomised to receive either intranasal DEX 1.5 μg kg (DEX group) or intranasal saline (Placebo group) 30 to 45 min before anaesthesia induction. MAIN OUTCOME MEASURES The incidence of PRAE. RESULTS Intranasal DEX significantly reduced the incidence of PRAE (P = 0.001), particularly oxygen desaturation (P = 0.012). Most PRAE were observed during the emergence phase. The incidence of PRAE was comparable among the three types of left-right shunt CHD children in both groups. In children aged less than 3 years, the incidence of PRAE was significantly lower in the DEX group (P = 0.003). In contrast, the incidence of PRAE was comparable between the two groups in children aged at least 3 years. No differences in the incidence of emergence agitation, fever and vomiting between the two groups were noted. CONCLUSION Administration of intranasal DEX 1.5 μg kg 30 to 45 min before induction led to a reduction in the incidence of PRAE in children aged less than 3 years with recent URI undergoing interventional cardiac catheterisation. TRIAL REGISTRATION chictr.org.cn identifier: ChiCTR-RRC-17012519.
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Abstract
Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles (
n
= 81), and these were followed by, case reports (
n
= 58), review articles (
n
= 10), letter to the editor (not as case reports but as a communication;
n
= 13), editorials (
n
= 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjana Kathiravan
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devakshi Dua
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Zhang X, Bai Y, Shi M, Ming S, Jin X, Xie Y. 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. Transl Pediatr 2021; 10:929-957. [PMID: 34012842 PMCID: PMC8107879 DOI: 10.21037/tp-21-105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Xu Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan Bai
- Department of Anesthesiology, The Second Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Min Shi
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shaopeng Ming
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaogao Jin
- Department of Anesthesiology, The Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Meyburg J, Ries M. Publication bias in pediatric emergence delirium: a cross-sectional analysis of ClinicalTrials.gov and ClinicalTrialsRegister.eu. BMJ Open 2020; 10:e037346. [PMID: 33060081 PMCID: PMC7566730 DOI: 10.1136/bmjopen-2020-037346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Emergence delirium (ED) is a frequent and potentially serious complication of general anaesthesia in children. Although there are various treatment strategies, no general management recommendations can be made. Selective reporting of study results may impair clinical decision-making. We, therefore, analysed whether the results of completed registered clinical studies in patients with paediatric ED are publicly available or remain unpublished. DESIGN Cross-sectional analysis. SETTING ClinicalTrials.gov and ClinicalTrialsRegister.eu. PARTICIPANTS AND OUTCOME MEASURES We determined the proportion of published and unpublished studies registered at ClinicalTrials.gov and ClinicalTrialsRegister.eu that were marked as completed by 1st September 2018. The major trial and literature databases were used to search for publications. In addition, the study investigators were contacted directly. For published trials, time to publication was calculated as the difference in months between study completion date and publication date. RESULTS Of the 44 registered studies on paediatric ED, only 24 (54%) were published by September 2019. Published trials contained data from n=2556 patients, whereas n=1644 patients were enrolled in unpublished trials. Median time to publication was 19 months. Studies completed in recent years were published faster, but still only 9 of 24 trials were published within 12 months of completion. CONCLUSION There is a distinct publication gap in clinical research in paediatric ED that may have an impact on meta-analyses and clinical practice.
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Affiliation(s)
- Jochen Meyburg
- Department of General Pediatrics and Pediatric Intensive Care, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Ries
- Department of Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Dexmedetomidine: What's New for Pediatrics? A Narrative Review. J Clin Med 2020; 9:jcm9092724. [PMID: 32846947 PMCID: PMC7565844 DOI: 10.3390/jcm9092724] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
Over the past few years, despite the lack of approved pediatric labelling, dexmedetomidine’s (DEX) use has become more prevalent in pediatric clinical practice as well as in research trials. Its respiratory-sparing effects and bioavailability by various routes are only some of the valued features of DEX. In recent years the potential organ-protective effects of DEX, with the possibility for preserving neurocognitive function, has put it in the forefront of clinical and bench research. This comprehensive review focused on the pediatric literature but presents relevant, supporting adult and animal studies in order to detail the recent growing body of literature around the pharmacology, end-organ effects, organ-protective effects, alternative routes of administration, synergetic effects, and clinical applications, with considerations for the future.
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Menser C, Smith H. Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients. Local Reg Anesth 2020; 13:73-83. [PMID: 32801855 PMCID: PMC7394591 DOI: 10.2147/lra.s181459] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/05/2020] [Indexed: 12/21/2022] Open
Abstract
Emergence from anesthesia can be associated with a wide spectrum of cognitive and behavioral dysregulation in children, including delirium or acute brain dysfunction. This period of neurobehavioral recovery can be further confounded by pain, anxiety, and fear. The implementation of monitoring for level of consciousness, pain, and delirium using valid pediatric tools is necessary to avoid misdiagnosis due to overlapping symptomatology and support appropriate management. Understanding the epidemiology of delirium in the postoperative setting will require consistent use of accurate terminology in the medical literature. The current interchangeable use of the terms “emergence agitation” and “emergence delirium” needs to be highlighted and awareness of differences in patient conditions and assessment tools is essential. We discuss epidemiology of emergence agitation and delirium in the pediatric population, and the challenges for future delineation of monitoring and management. Furthermore, we describe the possible impact of long-term consequences of emergence delirium among infants and children, and the necessary areas of future research.
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Affiliation(s)
- Carrie Menser
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heidi Smith
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Rao Y, Zeng R, Jiang X, Li J, Wang X. The Effect of Dexmedetomidine on Emergence Agitation or Delirium in Children After Anesthesia-A Systematic Review and Meta-Analysis of Clinical Studies. Front Pediatr 2020; 8:329. [PMID: 32766178 PMCID: PMC7381209 DOI: 10.3389/fped.2020.00329] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/20/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Yang X, Hu Z, Peng F, Chen G, Zhou Y, Yang Q, Yang X, Wang M. Effects of Dexmedetomidine on Emergence Agitation and Recovery Quality Among Children Undergoing Surgery Under General Anesthesia: A Meta-Analysis of Randomized Controlled Trials. Front Pediatr 2020; 8:580226. [PMID: 33304867 PMCID: PMC7694572 DOI: 10.3389/fped.2020.580226] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Xiaoli Yang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zhenyu Hu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Fei Peng
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Guangxiang Chen
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yu Zhou
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Qiange Yang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoling Yang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Maohua Wang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Clonidine in pediatric anesthesia: the new panacea or a drug still looking for an indication? Curr Opin Anaesthesiol 2019; 32:327-333. [PMID: 31045639 DOI: 10.1097/aco.0000000000000724] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Clonidine, an α2-receptor agonist is a widely used drug in pediatrics with a large scope of indications ranging from prevention of postoperative emergence agitation, analgesia, anxiolysis, sedation, weaning to shivering. In the era of 'opioid-free' medicine with much attention be directed toward increasing problems with opioid use, clonidine due to its global availability, low cost and safety profile has become an even more interesting option. RECENT FINDINGS Increasing evidence from randomised clinical trials support the use of clonidine in healthy children in the perioperative setting. Clonidine appears to significantly reduce postoperative emergence agitation, opioid consumption, shivering, nausea and vomiting. In addition, emerging evidence support the use of clonidine for sedation of critically ill children in ICUs. In this review, the current evidence for clonidine in pediatrics is described and analyzed including a meta-analysis for prevention of emergence agitation. SUMMARY Clonidine appears a safe and beneficial drug with moderate to high-quality evidence supporting its use in pediatric anesthesia. However, for some indications and populations such as children younger than 12 months old and those with hemodynamic instability, there is an urgent need for high-quality trials.
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Zhang H, Fan Q, Zhang J, Wu B, Wang X, Zhang Y, Wang A. Effect of ultrasound-guided lumbar plexus block on emergence agitation in children undergoing hip surgery: study protocol for a randomized controlled trial. Trials 2019; 20:22. [PMID: 30616597 PMCID: PMC6323822 DOI: 10.1186/s13063-018-3140-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 12/17/2018] [Indexed: 11/16/2022] Open
Abstract
Background Emergence agitation (EA) is a common postoperative issue in children that causes self-injury, increases stress on healthcare team members, and even leads to postoperative maladaptive behavioral changes in children. Clear answers regarding a ‘gold standard’ for prevention of EA are not available. Pain is regarded as an important causative factor of EA, and ultrasound-guided lumbar plexus block is a safe and efficient anesthetic method that can provide satisfactory pain relief in pediatric hip surgery. The purpose of our study is to determine whether ultrasound-guided lumbar plexus block can reduce the incidence of EA in children undergoing hip surgery. Methods/design We designed a prospective, randomized, controlled, blinded trial to determine the effect of ultrasound-guided lumbar plexus block on EA. A total of 100 American Society of Anesthesiologists class I–II children (1–6 years old) scheduled for elective hip surgery will be recruited for this study. Participants will be randomized at a 1:1 ratio to receive either ultrasound-guided lumbar plexus block or fentanyl after the induction of general anesthesia. The primary outcome is the incidence of EA 30 min after emergence from anesthesia using the Pediatric Anesthesia Emergence Delirium (PAED) score. The secondary outcomes are the severity and duration of EA 30 min after emergence from anesthesia using the PAED score, postoperative pain evaluated by the Children’s Hospital of Eastern Ontario Pain Scale, and the incidence of postoperative adverse events. Randomization will be conducted using a computer-generated randomization schedule. Outcome assessors and data collectors will be blinded to the group allocations. Assessments will be performed before surgery, intraoperatively, and postoperatively at every time point. Discussion Our hypothesis in this trial is that ultrasound-guided lumbar plexus block can decrease the incidence of EA in children undergoing elective hip surgery. This trial will provide clinical answers to verify our hypothesis. If our hypothesis is confirmed, the results could provide a safe method to prevent EA. Trial registration Chinese Clinical Trial Registry, ChiCTR-INR-17011525. Registered on 30 May 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3140-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hui Zhang
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, No. 600, Yishan Road, Shanghai, 200233, China
| | - Qing Fan
- Department of Pediatric Orthopedics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Junfeng Zhang
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, No. 600, Yishan Road, Shanghai, 200233, China
| | - Bin Wu
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, No. 600, Yishan Road, Shanghai, 200233, China
| | - Xiaofeng Wang
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, No. 600, Yishan Road, Shanghai, 200233, China
| | - Yu Zhang
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, No. 600, Yishan Road, Shanghai, 200233, China
| | - Aizhong Wang
- Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, No. 600, Yishan Road, Shanghai, 200233, China.
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Mason KP. Paediatric emergence delirium: a comprehensive review and interpretation of the literature. Br J Anaesth 2018; 118:335-343. [PMID: 28203739 DOI: 10.1093/bja/aew477] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
There remain unanswered questions and implications related to emergence delirium in children. Although we know that there are some predisposing factors to emergence delirium, we still are unable to predict accurately those who are at greatest risk. Emergence delirium should be considered as a ‘vital sign’, which should be followed and documented in every child in the postanaesthesia recovery period. Standardized screening tools should be adopted for paediatric emergence delirium.
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Wang F, Zhong H, Xie X, Sha W, Li C, Li Z, Huang Z, Chen C. Effect of intratracheal dexmedetomidine administration on recovery from general anaesthesia after gynaecological laparoscopic surgery: a randomised double-blinded study. BMJ Open 2018; 8:e020614. [PMID: 29643163 PMCID: PMC5898314 DOI: 10.1136/bmjopen-2017-020614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 02/15/2018] [Accepted: 02/23/2018] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To examine the efficacy of intratracheal dexmedetomidine (Dex) injection for the prevention of the laryngeal response on emergence from general anaesthesia following gynaecological laparoscopic surgery. DESIGN Prospective, randomised, double-blinded, controlled trial. SETTING A general hospital, Guangdong Province, China. PARTICIPANTS All patients who underwent elective laparoscopic gynaecological surgery, aged 18-60 years old, 40-80 kg in weight, American Society of Anesthesiologists class I-II were eligible. Patients were excluded if they had respiratory disease, heart disorders which might represent risk factors of potential complications of Dex such as bradycardia, heart block, coronary heart disease, uncontrolled hypertension or the long-term use of sedative drugs. INTERVENTION Patients were randomly allocated to either receive intratracheal Dex (DT), intravenous Dex (DV) or intravenous saline (CON, n=30, respectively). In the DT and DV groups, Dex (0.5 µg/kg) was diluted and mixed in 1 or 20 mL of saline, respectively, and injected via the intratracheal or intravenous route 30 min before the completion of the surgery. OUTCOME MEASURES The primary outcome was the coughing extent among the three groups. Secondary outcomes included awareness time, extubation time, postoperative visual analogue scale and Steward recovery score. RESULTS Compared with the CON group, the extent of coughing was significantly reduced in both the DV group and the DT group. Furthermore, the mean time to awareness (13.4 (4.3) vs 8.8 (2.9), p<0.001) and the extubation time (14.3 (4.3) vs 8.4 (3.6), p<0.001) were reduced in the DT group. Patients in the DT group also experienced better early recovery quality and less pain than those in the CON group. Furthermore, intratracheal Dex administration contributed to improved stability in haemodynamics with no significant side effects. CONCLUSIONS Intratracheal Dex administration may avoid untoward laryngeal responses for patients emerging from general anaesthesia after gynaecological laparoscopy. TRIAL REGISTRATION NUMBER ChiCTR-IOR-15007611.
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Affiliation(s)
- Fei Wang
- Department of Anesthesiology and Pain Medicine, Guangdong Medical College, Huizhou First People’s Hospital, Huizhou, Guangdong, China
| | - Haoxiang Zhong
- Department of Anesthesiology and Pain Medicine, Guangdong Medical College, Huizhou First People’s Hospital, Huizhou, Guangdong, China
| | - Xiaoyan Xie
- Department of Anesthesiology and Pain Medicine, Guangdong Medical College, Huizhou First People’s Hospital, Huizhou, Guangdong, China
| | - Weiping Sha
- Department of Anesthesiology and Pain Medicine, Guangdong Medical College, Huizhou First People’s Hospital, Huizhou, Guangdong, China
| | - Caili Li
- Department of Anesthesiology and Pain Medicine, Guangdong Medical College, Huizhou First People’s Hospital, Huizhou, Guangdong, China
| | - Zhenping Li
- Department of Anesthesiology and Pain Medicine, Guangdong Medical College, Huizhou First People’s Hospital, Huizhou, Guangdong, China
| | - Zhuomei Huang
- Department of Anesthesiology and Pain Medicine, Guangdong Medical College, Huizhou First People’s Hospital, Huizhou, Guangdong, China
| | - Chaojin Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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17
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The effects of intranasal dexmedetomidine premedication in children: a systematic review and meta-analysis. Can J Anaesth 2017. [DOI: 10.1007/s12630-017-0917-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Feng JF, Wang XX, Lu YY, Pang DG, Peng W, Mo JL. Effects of dexmedetomidine versus midazolam for premedication in paediatric anaesthesia with sevoflurane: A meta-analysis. J Int Med Res 2017; 45:912-923. [PMID: 28425829 PMCID: PMC5536403 DOI: 10.1177/0300060517704595] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Dexmedetomidine (DEX), an α2-adrenergic receptor agonist, produces ideal sedation and early postoperative recovery for premedication in paediatric surgery, reducing preoperative anxiety and facilitating smooth induction of anaesthesia. We performed a meta-analysis to compare the effects of DEX and midazolam (MDZ) in paediatric anaesthesia with sevoflurane. Methods PubMed, Ovid, Web of Science, and Public Health Management Corporation were searched through December 2016 for randomized controlled trials (RCTs) that compared DEX and MDZ in children undergoing sevoflurane anaesthesia. The risk ratio (RR) with 95% incidence interval (95%CI) was used for dichotomous variables. Results Twelve RCTs involving 422 patients in the DEX group and 448 patients in the MDZ group were included. Patients in the DEX group had a significantly lower incidence of unsatisfactory sedation (RR [95%CI] = 0.71 [0.57-0.89]), unsatisfactory parental separation (RR [95%CI] = 0.56 [0.35-0.87]), and rescue analgesia (RR [95%CI] = 0.52 [0.35-0.77]) than patients in the MDZ group. However, both groups had a similar incidence of unsatisfactory mask acceptance, emergence agitation, and postoperative nausea and vomiting. Conclusion Compared with MDZ, DEX is beneficial in paediatric anaesthesia with sevoflurane because of its lower incidence of unsatisfactory sedation, parental separation, and rescue analgesia.
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Affiliation(s)
- Ji-Feng Feng
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Xiao-Xia Wang
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Yan-Yan Lu
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Deng-Ge Pang
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Wei Peng
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Jian-Lan Mo
- Department of Anesthesiology, Obstetrics & Gynecology Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Sun Y, Li Y, Sun Y, Wang X, Ye H, Yuan X. Dexmedetomidine Effect on Emergence Agitation and Delirium in Children Undergoing Laparoscopic Hernia Repair: a Preliminary Study. J Int Med Res 2017; 45:973-983. [PMID: 28470100 PMCID: PMC5536412 DOI: 10.1177/0300060517699467] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the safety and efficacy of dexmedetomidine (Dex) to prevent emergence agitation (EA) and delirium (ED) in children undergoing laparoscopic hernia repair under general anesthesia. Methods 100 children (1-5 years, 10-25 kg) were randomized into four groups: controls (saline) and intravenous Dex at 0.25, 0.5, and 1.0 µg/kg (D1, D2, D3, respectively). Dex/saline infusion was started following anesthesia. EA and ED were evaluated on a 5-point scale. Results For the C, D1, D2, and D3 groups, respectively, EA frequencies were 45.8%, 30.4%, 12%, 4%; ED frequencies 29.1%, 13%, 4%, 4%; CHIPPS scores 8, 6, 3, 3; sevoflurane doses from 13.2 ± 3.4 (controls) to 9.4 ± 3.5 ml (D3). Intervals until mask removal/spontaneous eye opening were significantly longer for D2 and D3 than controls. PACU stay was longer for D3. Conclusions There was significantly less postoperative EA and pain, with less sevoflurane required, using Dex.
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Affiliation(s)
- Yingying Sun
- 1 Department of Anesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui, China.,2 Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yuanhai Li
- 2 Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yajuan Sun
- 1 Department of Anesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui, China
| | - Xing Wang
- 1 Department of Anesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui, China
| | - Hongwu Ye
- 1 Department of Anesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui, China
| | - Xianren Yuan
- 1 Department of Anesthesiology, Anhui Provincial Children's Hospital, Hefei, Anhui, China
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Wang X, Deng Q, Liu B, Yu X. Preventing Emergence Agitation Using Ancillary Drugs with Sevoflurane for Pediatric Anesthesia: A Network Meta-Analysis. Mol Neurobiol 2016; 54:7312-7326. [DOI: 10.1007/s12035-016-0229-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 10/16/2016] [Indexed: 01/10/2023]
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