Comparative Effects of Total Intravenous Anesthesia with Propofol and Remifentanil Versus Inhalational Sevoflurane with Dexmedetomidine on Emergence Delirium in Children Undergoing Strabismus Surgery

Global prevalence and risk factors of emergence delirium in pediatric patients undergoing general anesthesia: A systemic review and meta-analysis

PROBLEM

Emergence delirium (ED) in children post-general anesthesia has been persistently underestimated, impacting the well-being of children, nurses, and even parents. This study employs integrated analysis to establish a comprehensive understanding of ED, including its occurrence and related risk factors, emphasizing the imperative for enhanced awareness and comprehension among pediatric nursing care providers.

ELIGIBILITY CRITERIA

A systematic review and meta-analysis were conducted using four electronic databases, namely PubMed, CINAHL via EBSCOhost, Embase via Elsevier, and ProQuest Dissertations and Theses.

RESULTS

This meta-analysis included 16 studies involving 9598 children who underwent general anesthesia. The pooled prevalence of ED was 19.2% (95% confidence interval [CI] = 0.12 to 0.29), with younger patients exhibiting a higher prevalence of ED. ED research is scant in Africa and is mostly limited to the Asia Pacific region and Northern Europe. Neck and head surgery (odds ratio [OR] = 2.34, 95% CI = 1.29 to 4.27) were significantly associated with ED risk.

CONCLUSIONS

ED should be monitored in children who receive general anesthesia. In this study, ED had a prevalence rate of 19.2%, and head and neck surgery were significantly associated with ED risk. Therefore, healthcare professionals should carefully manage and prevent ED in children undergoing general anesthesia.

IMPLICATIONS

A comprehensive understanding of ED's prevalence and risk factors is crucial for enhancing nursing care. Adopting a family-centered care approach can empower parents with information to collaboratively care for their children, promoting a holistic approach to pediatric healthcare.

Effect of Dexmedetomidine Combined with Remifentanil on Emergence Agitation During Awakening from Sevoflurane Anesthesia for Pediatric Liver Surgery

BACKGROUND We aimed to assess the effect of dexmedetomidine (Dex) combined with remifentanil on emergence agitation (EA) during awakening from sevoflurane anesthesia for pediatric liver surgery. MATERIAL AND METHODS Sixty children who underwent liver surgery in our hospital were prospectively selected and randomly allocated into group A (placebo+remifentanil+sevoflurane) or group B (Dex+remifentanil+sevoflurane). Mean arterial pressure (MAP) and heart rate (HR) at different time points, agitation score during awakening, behavioral status, pain level, and the incidence of postoperative adverse effects were compared in both groups. RESULTS Children in group B had lower HR and MAP levels immediately after tracheal extubation and 5 min after tracheal extubation than those in group A. The Aono's scores, PAED agitation scores, and CHIPP scores at 15 min and 30 min of admission to the PACU were lower in group B than in group A. The incidence of agitation during postoperative anesthesia awakening was lower in group B in contrast to group A. There was no significant difference in postoperative adverse reactions between group A and group B. CONCLUSIONS In pediatric liver surgery, the use of Dex+remifentanil+sevoflurane anesthesia can reduce the incidence of EA during the awakening period, stabilize hemodynamic levels, and relieve postoperative pain, and has fewer postoperative adverse effects, which warrants clinical application.

Post-operative vomiting after pediatric strabismus surgery: A comparison of propofol versus sevoflurane anaesthesia

Background and Aims

Squint surgery is a risk factor for postoperative vomiting (POV) in children. This study was designed to compare the incidence of POV in children undergoing strabismus surgery under balanced anesthesia with sevoflurane versus intravenous anesthesia with propofol.

Material and Methods

In this prospective randomized controlled study conducted in a tertiary care ophthalmology hospital, 70 ASA I-II children aged 1-12 years undergoing strabismus surgery were randomized to two groups -Group S (sevoflurane-based anesthesia) and Group P (propofol-based anesthesia) for maintenance. The surgical details, intraoperative hemodynamic parameters, recovery characteristics, and emergence delirium were recorded. Any episode of postoperative vomiting in the 0-2 hours, 2-6 hours, and 6-24 hours period was noted. Rescue antiemetic was administered if there was more than one episode of vomiting.

Results

Both the groups were similar with respect to demographic and surgical details. The average duration of surgery was 118.2 ± 41.88 min in group S and 137.32 ± 39.09 min in group P (P = .05). Four children in group S (11.4%) and one child in group P (2.9%) had POV in the first 24 hours but this was not statistically significant (P = .36). The median time to discharge from post anesthesia care unit was significantly less (P = .02) in the P group (50 min) than in the S group (60 min).

Conclusion

Propofol-based anesthesia does not offer advantage over sevoflurane, in reducing POV after squint surgery, when dual prophylaxis with dexamethasone and ondansetron is administered. It, however, reduces the duration of stay in the post anesthesia care unit.

Systematic review and meta-analysis comparing the efficacy of dexmedetomidine to midazolam as premedication and a sedative agent in pediatric patients undergoing dental procedures

INTRODUCTION

Pediatric dental surgeries are associated with the emotions of fear, anxiety, and other behavioral disturbances of children that need to be managed. Sedation using drugs like dexmedetomidine (DEX) and midazolam (MID) is a common pharmacological behavior managing technique. We conducted this meta-analysis to evaluate the efficacy of both these drugs in current literature.

METHODOLOGY

A thorough literature search was conducted on PubMed, MEDLINE, Google Scholar, and Cochrane's database for randomized studies that compared sedative efficacy of dexmedetomidine with midazolam in children of 0-15 years of age undergoing dental surgeries. Sedation in children during dental procedure, when used as a premedication, at the time of separation from parents and at the time of mask induction, onset time, duration of anesthesia, and surgery were evaluated. The mean differences (MDs), odds ratio (OR), and their 95% confidence intervals (CIs) were calculated both for continuous and dichotomous outcome data using random-effects model.

RESULTS

Seven studies met out inclusion criteria and were analyzed. Results of premedication with DEX was associated with more anxiolysis (OR=0.29, 95% CI: 0.17-0.52, p=0.0001; I2=0%) and at the time of separation from parents (OR=0.36, 95% CI: 0.19-0.69, p=0.002; I2=52%) in comparison to MID. No significant differences in results were seen at mask induction (OR=0.63, 95% CI: 0.34-1.18, p=0.15; I2=47%) and for sedation in children during dental procedures (OR=0.52, 95% CI: 0.07-3.70, p=0.51; I2=72%). Also, there were no significant differences in onset time, duration of anesthesia, and surgery between the two agents.

CONCLUSION

DEX proved to be a better premedicant than MID for pediatric patients. No significant difference in efficacy of both sedative agents was observed in children undergoing dental treatment. More clinical trials need to be conducted to see its efficacy in dental surgeries in children of standardized ages and with standard doses.

The preventive effect of dexmedetomidine on anesthesia complications in strabismus surgery: a systematic review and meta-analysis

OBJECTIVE

Dexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated with strabismus surgery, including postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex. However, its effectiveness and side effects of the present studies are different. The sample sizes of the present studies on the prevention of complications of dexmedetomidine are small. Therefore, this study evaluates the efficacy of dexmedetomidine in preventing anesthesia-related complications in strabismus surgery through a systematic review and meta-analysis.

METHODS

Literature was retrieved from 10 commonly used databases and randomized controlled trials published up to May 2022 were sought. The included studies compared the intervention effects of dexmedetomidine versus placebo on anesthesia-related complications in surgery. The occurrence rates of postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex in patients undergoing strabismus surgery were evaluated. Statistical analyses and forest plots were generated using Review Manager and STATA software. Binary outcomes were measured using relative risk (RR) with a 95% confidence interval for each outcome. The Cochrane risk of bias tool was used to assess the bias and risk in the studies that met the inclusion criteria.

RESULTS

A total of 13 articles were ultimately included in the analysis, comprising 1,018 patients who underwent strabismus surgery. The dexmedetomidine group, compared to the placebo group, demonstrated significant reductions in the incidence of postoperative delirium (RR = 0.73, P = 0.001), severe postoperative delirium (RR = 0.45, P = 0.005), postoperative nausea and vomiting (RR = 0.48, P < 0.0001), and the need for supplemental analgesia postoperatively (RR = 0.60, P = 0.004). Additionally, subgroup analysis revealed that intravenous administration of dexmedetomidine significantly reduced the incidence of oculocardiac reflex (RR = 0.50, P = 0.001). In contrast, intranasal administration of dexmedetomidine did not have a significant effect on the incidence of oculocardiac reflex (RR = 1.22, P = 0.15). There was a significant difference between the subgroups (P = 0.0005, I2 = 91.7%).

CONCLUSION

Among patients undergoing strabismus surgery, the use of dexmedetomidine can alleviate postoperative delirium and reduce the incidence of postoperative nausea and vomiting, as well as postoperative pain. Moreover, intravenous administration of dexmedetomidine can lower the occurrence rate of the oculocardiac reflex.

The Safety of Propofol Versus Sevoflurane for General Anesthesia in Children: A Meta-Analysis of Randomized Controlled Trials

Background

Propofol and sevoflurane are the most used anesthetics for pediatric surgery. Emergence agitation, postoperative nausea and vomiting and postoperative pain are the primary adverse effect of these general anesthetics. Many clinical studies had compared the safety of propofol and sevoflurane in pediatric surgery, but the results were controversial.

Objectives

To evaluate the evidence surrounding the safety of propofol versus sevoflurane for general anesthesia in children.

Methods

Databases including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data and Vip Data were searched to collect relevant articles. Trials were strictly selected according to previously defined inclusion and exclusion criteria. RevMan 5.3 software was used for meta-analyses.

Results

Twenty randomized controlled trials recruiting 1,550 children for general anesthesia were included, with overall low-moderate methodological quality. There was evidence that compared with sevoflurane anesthesia, propofol anesthesia significantly decreased the incidence of emergence agitation (OR = 4.99, 95% CI, 3.67–6.80; P &lt; 0.00001), postoperative nausea and vomiting (OR = 1.91, 95% CI, 1.27–2.87; P  =  0.002) and postoperative pain (OR = 1.72, 95% CI, 1.11–2.64; P = 0.01) in children. However, patients who received sevoflurane tended to have shorter times to eye opening (MD = −2.58, 95% CI, −2.97– −2.19; P &lt; 0.00001) and times to extubation (MD = −1.42, 95% CI, −1.81– −1.02; P &lt; 0.00001).

Conclusions

This review reveals that the children who received propofol anesthesia had the lower risks of emergence agitation, postoperative nausea and vomiting and postoperative pain when compared with sevoflurane anesthesia. But the children who received sevoflurane recovered slightly faster than those received propofol. Considering the limitations of the included studies, better methodological quality and large controlled trials are expected to further quantify the safety of propofol and sevoflurane for general anesthesia in children.

Effect of Remifentanil on Postoperative Vomiting After Strabismus Surgery in Preschool Children: A Prospective Randomized Controlled Trial

Background

Strabismus surgery and the use of opioid are risk factors of postoperative vomiting. We evaluated whether there is a dose-dependent effect of remifentanil on the incidence of postoperative vomiting.

Methods

Sixty pediatric patients who were scheduled for strabismus surgery were enrolled. Patients were randomly divided into three groups; Group H (high-dose remifentanil group), Group L (low-dose remifentanil group), and Group C (control group). After endotracheal intubation, patients in the Group H and L received an intravenous bolus dose of remifentanil of 1.0 μg/kg and 0.5 μg/kg over 2 min, respectively. Group H and L patients received a continuous infusion of remifentanil (0.1 μg/kg/min) during the surgery. The patients in Group C did not have any dose of remifentanil. Intravenous fentanyl (1 µg/kg) was administered to the patients for postoperative pain control.

Results

The primary outcome was a difference of the incidence of postoperative vomiting within 24 hours after surgery. There was no significant difference in incidence of postoperative vomiting between three groups. The degree of emergence agitation and postoperative pain did not show any significant difference between three groups.

Conclusions

The intraoperative administration of remifentanil did not show dose-dependent effect on postoperative vomiting in pediatric strabismus surgery.

The efficacy and safety of dexmedetomidine in preventing emergence delirium in paediatric patients following ophthalmic surgery: a systematic review and meta-analysis of randomised controlled trials

Background

The leading cause of emergence delirium (ED) in children postoperatively is the exposure to inhalational anaesthetics. ED can occur immediately after waking from anaesthesia, making patients generally uncooperative and agitated. Dexmedetomidine has sedative and analgesic effects and helps to reduce agitation and delirium and improve hemodynamic stability and the recovery of respiratory function; in addition to decreasing pain intensity, it is also well known for helping reduce nausea and vomiting.

Objectives

This updated systematic review meta-analysis investigate and summarise currently available evidence on the use of dexmedetomidine to prevent ED, reduce postoperative nausea and vomiting (PONV) and decrease the need for rescue analgesia in paediatric patients undergoing ophthalmic surgery.

Methods

The medical databases EMBASE, PubMed and Cochrane Library were searched for randomised controlled trials published between January 2020 and August 2022 that used Dexmedetomidine in paediatric patients undergoing ophthalmic surgery. The protocol was prospectively registered with PROSPERO (CRD42022343622). The review was accomplished according to the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’, and the meta-analysis was conducted by using RevMan5.4. These studies examine the efficacy of dexmedetomidine in preventing ED in children undergo ophthalmic surgery. The Cochrane ROB-1 was used to assess risk of bias (ROB).

Results

Eight studies comprised of 629 participants, of which 315 received dexmedetomidine and 314 placebos were examined. PAED score identified ED following surgery. A review and meta-analysis indicated that dexmedetomidine reduces ED incidence (RR = 0.39; 95% CI 0.25–0.62). Similarly, it reduces the use of rescue analgesia (RR = 0.38; 95% CI 0.25–0.57). However, dexmedetomidine did not help prevent PONV since no difference was found between groups (RR = 0.33; 95% CI 0.21–0.54).

Conclusion

This review showed that dexmedetomidine helped to reduce ED incidence in paediatric patients after ophthalmic surgery and reduced the need for rescue analgesia compared to placebo or other medications.

A Comparative Study on the Effects of Ketofol, Dexmedetomidine, and Isofol in Anesthesia of Candidates for Dilatation and Curettage

Background

Dilatation and curettage (D & C) is one of the relatively common surgeries among women. Familiarity with the analgesics, along with their different uses and specific characteristics, can help to determine the best and most appropriate drug to control pain in the patients.

Objectives

This study aimed to compare the effects of ketofol, dexmedetomidine, and isofol in anesthesia of candidates for D & C.

Methods

In this double-blind clinical trial, 150 candidates for D & C surgeries with ASA class 1 and 2 were included. Patients were randomly divided into three groups. The first group received ketamine + propofol, the second group received dexmedetomidine, and the third group received isofol (isoflurane + propofol). Any hemodynamic changes or respiratory disorders, including apnea or hypoventilation, drop in the level of blood oxygen saturation, and the need for respiratory support, were recorded and compared.

Results

Hypoventilation was observed in 47 patients in isofol group, 18 in the dexmedetomidine group, and 42 in ketofol group. Also, 48 patients in the isofol group, eight in the dexmedetomidine group, and 33 in the ketofol group experienced apnea. Moreover, 17 patients in the dexmedetomidine group, 35 in the ketofol group, and eight in the isofol group experienced bradycardia. The rate of bradycardia was significantly higher in the dexmedetomidine group (70%) compared to the other two groups, and the rate of hypotension was significantly higher in the isofol group (P = 0.001).

Conclusions

According to the results, dexmedetomidine was associated with fewer complications during general anesthesia in D & C surgery.

Comparison of the Effect of Propofol and Dexmedetomidine on Hemodynamic Parameters and Stress Response Hormones During Laparoscopic Cholecystectomy Surgery

Background

General anesthesia induces endocrine, immunologic, and metabolic responses. Anesthetic drugs affect the endocrine system by changing the level of stress hormones and hemodynamic variables of the patient.

Objectives

The purpose of this study was to compare the effects of propofol and dexmedetomidine on hemodynamic parameters and stress-induced hormones in laparoscopic cholecystectomy (LC) surgery.

Methods

Seventy patients of elective LC were included in this study. The patients were randomly assigned into two equal groups of propofol (75 µg/kg/min) and dexmedetomidine (0.5 µg/kg/hour) as anesthesia maintenance. Hemodynamic parameters (heart rate and mean atrial pressure), blood sugar, and serum epinephrine level were monitored and recorded from pre-anesthesia period to 10 min after entry to post-anesthesia care unit (PACU) according to a planned method.

Results

Heart rate and mean atrial pressure changes were significantly lower in dexmedetomidine group in all stages compared to propofol group (P < 0.001). Also, the rises in blood glucose and serum epinephrine levels in the dexmedetomidine group were significantly higher than in the propofol group (P < 0.001).

Conclusions

Anesthesia maintenance by dexmedetomidine showed a significant difference in hemodynamic parameters in comparison with propofol. While dexmedetomidine had better effects on controlling hemodynamic parameters, propofol showed better effects on decreasing stress hormones, and it can be suggested for LC surgery.

Effects of the Two Doses of Dexmedetomidine on Sedation, Agitation, and Bleeding During Pediatric Adenotonsillectomy

Background

Due to the importance of dexmedetomidine and its different dosages, here, we aimed to investigate and compare the effectiveness of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine in sedation, agitation, and bleeding in pediatrics undergoing adenotonsillectomy.

Methods

This double-blinded randomized clinical trial was performed on 105 pediatric patients that were candidates for adenotonsillectomy. Then, the patients were divided into three groups receiving dexmedetomidine at a dose of 2 µg/kg, diluted dexmedetomidine at 1 µg/kg, and normal saline. The drugs were administered 15 minutes before operations via the intravenous method. The duration of extubation, mean arterial pressure (MAP), heart rate (HR), and SPO₂ in the recovery were recorded. We also collected data regarding patients’ sedation and agitation every 15 minutes.

Results

Our data showed no significant differences between the groups of patients regarding MAP, HR, and SPO₂. However, the mean sedation score was significantly higher in patients receiving dexmedetomidine (2 µg/kg), and this score was lowest in the control group at the time of entrance to the recovery room. The patients that received dexmedetomidine at a dose of 1 µg/kg had the lowest agitation score after 45 minutes of being in the recovery room, and the patients treated with dexmedetomidine at a dose of 2 µg/kg had the lowest agitation score after 60 minutes of being in the recovery compared to other groups of patients.

Conclusions

The use of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine was associated with proper sedation and a significant reduction in agitation. The patients also had lower amounts of bleeding. We recommend that anesthesiologists should pay more attention to dexmedetomidine at a dose of 2 µg/kg, especially in pediatric surgical procedures.

Practical Considerations for Dexmedetomidine Sedation in Adult Cataract Surgery Under Local/Regional Anesthesia: A Narrative Review

Cataract surgery is predominantly performed under local/regional anesthesia, with or without sedation. The practice pattern of sedation is unknown and seems to vary significantly among institutions and countries, routinely administered in some parts of the world to the other extreme of none at all. The selection of sedative agents and techniques varies widely. Currently, there is no ideal sedative agent. Dexmedetomidine has gained recent attention for sedation in ophthalmic local/regional anesthesia due to its alleged advantages of effective sedation with minimal respiratory depression, decreased intraocular pressure, and reduced pain during the local anesthetic injection; however, they are subject to differing interpretations. Published literature also suggests that although dexmedetomidine sedation for cataract surgery under local/regional anesthesia is potentially useful, its role may be limited due to logistical difficulties in administering the recommended dose.

Evaluation of the Adding Paracetamol to Dexmedetomidine in Pain Management After Adult Cardiac Surgery

Background

Postoperative pain control after cardiac surgery is usually based on Opioids. These drugs are associated with side effects, and the use of drugs with fewer side effects is important for analgesia. Dexmedetomidine and paracetamol have fewer side effects than opioids.

Objectives

The aim of the study was to evaluate the adding paracetamol to dexmedetomidine continuous infusion pump for pain management after adult cardiac surgery.

Methods

In this study, 100 patients were divided into two groups. One group received a continuous infusion of dexmedetomidine and paracetamol (DP), and the other received dexmedetomidine (D). These two groups were evaluated for MAP, HR, and the need for prescribing opioids before and after extubation. Also, duration of intubation and pain before extubation and 36 hours after every 4 hours.

Results

Patients in the DP group had lower mean MAP and HR during intubation period than the D group and needed fewer opioids and doses of opioids in addition to drug study infusion pre- (P = 0.001) and post-extubation (P = 0.001 and P = 0.022, respectively). The DP group patients were extubated earlier (P = 0.001). After extubation, the DP group had less pain than the D group.

Conclusions

This study showed that adding paracetamol to the dexmedetomidine infusion pump can provide better analgesia.

Topical Sevoflurane: A Novel Treatment for Chronic Pain Caused by Venous Stasis Ulcers

In the US, an estimated 1 - 2% of chronic venous insufficiency (CVI) patients (of 6 - 7 million nationwide) develop at least one venous stasis ulcer (VSU) during their illness. Of these, approximately 40% develop subsequent ulcers, making VSU prognostically poor. Current management of VSU is costly, with poor prognosis, high recurrence rate, inadequate pain management, and significantly reduced quality of life (QoL). Topical volatile anesthetic agents, such as sevoflurane, offer improved pain relief and symptom control in patients suffering from chronic VSU. The immediate impact of topical sevoflurane in reducing pain associated with ulcer bed debridement has several implications in improving the quality of life in patients with CVI induced ulcers and in the prognosis and healing of the ulcers. This review summarizes a topical formulation of a volatile anesthetic and its implications for the management of VSUs.