Atomised intranasal dexmedetomidine versus oral melatonin in prevention of emergence delirium in children undergoing ophthalmic surgery with sevoflurane

Abstract

BACKGROUND Melatonin and dexmedetomidine have both been used as a premedication to decrease emergence delirium in children. The effectiveness of oral melatonin, compared with atomised intranasal dexmedetomidine, in this role is not well studied. OBJECTIVETo study the efficacy of pre-operative atomised intranasal dexmedetomidine versus oral melatonin in children scheduled for ophthalmic surgery under sevoflurane.DESIGN A prospective, randomised, double-blind trial.SETTING Ophthalmic surgery in a university teaching hospital, April 2021 to October 2021.PATIENTS A total of 120 children undergoing ophthalmic surgery with sevoflurane anaesthesia.INTERVENTION Children were randomised to receive preoperative intranasal dexmedetomidine 2 mg/kg via an atomiser device (dexmedetomidine group) or oral melatonin 0.5 mg kg À1 (melatonin group), 45 min before surgery.OUTCOMES MEASURED The primary outcome was the incidence of emergence delirium assessed by the Paediatric Anaesthesia Emergence Delirium scale. Secondary outcomes included pre-operative sedation, quality of inhalational induction, postoperative sedation and pain. RESULTSThe incidence of emergence delirium was lower in the dexmedetomidine group than in the melatonin group (17 versus 37%, relative risk 0.45, 95% CI: 0.24 to 0.88; P ¼ 0.01). Children in the dexmedetomidine group were more sedated following premedication and in the postanaesthesia care unit (P < 0.05). Postoperative pain scores were lower in the dexmedetomidine group than in the melatonin group: 0 [0 to 3] versus 2.5 [0-4], (P ¼ 0.01). The requirement for and dose of rescue fentanyl analgesia postoperatively was comparable between the two groups.CONCLUSION Atomised intranasal dexmedetomidine significantly reduced emergence delirium in paediatric opthalmic procedures under sevoflurane anaesthesia compared to oral melatonin.TRIAL REGISTRATION Clinical Trials Registry of India CTRI/2021/03/032388 (www.ctri.nic.in)

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

“…If the score was >3, morphine was administered intravenously as rescue analgesia with dose of 25 ug kg -1 [ 19 ]. In addition, 0.1 mg kg -1 ondansetron was given intravenously as an antiemetic to all the patients in both groups postoperatively [ 12 , 15 , 17 ] (Tables 1 and 2 ; Figs. 2 and 3 ).…”

“…Compared to general surgery, ophthalmic surgery is less traumatic, but ED incidence is nonetheless significant [ 17 ]. Patients undergoing ophthalmologic surgery had an ED risk rate of 28% compared to orthopaedic, urologic or other general surgery [ 12 ].…”

“…Visual disturbances, fear of darkness and a lack of visual stimulation postoperatively can also lead to ED [ 17 ]. Moreover, anaesthetic choices, duration, surgery type and pain can contribute to ED occurrence [ 14 , 15 , 17 ]. As mentioned earlier, sevoflurane and desflurane are leading causes of ED, and both are commonly used in paediatric anaesthesia [ 4 , 20 ].…”

“…A meta-analysis by Amorim et al including RCTs that included paediatric patients undergoing elective procedures under general anaesthesia with sevoflurane found that dexmedetomidine helped to reduce the incidence of sevoflurane-induced ED compared to placebo [ 22 ]. However, in this review, seven included studies used sevoflurane for anaesthesia induction [ 12 – 17 , 19 ], and one used propofol [ 18 ]. Therefore, we could not perform a subgroup analysis.…”

“…Five studies administered dexmedetomidine intranasally [ 12 – 14 , 17 , 19 ]. It is recommended to administer dexmedetomidine intranasally as a preoperative anxiolytic because it is noninvasive, facilitates parental separation, helps reduce the anxiety of paediatric patients in the operating room and ensures a smooth induction of inhalation anaesthesia [ 19 ].…”