Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium

Abstract

BACKGROUND Emergence delirium is a common complication in paediatric anaesthesia associated with significant morbidity. Total intravenous anaesthesia (TIVA) and intra-operative dexmedetomidine as an adjuvant to sevoflurane anaesthesia can both reduce the incidence of emergence delirium compared with sevoflurane alone, but no studies have directly compared their relative efficacy. OBJECTIVE The study objective was to compare the effects of TIVA and dexmedetomidine on the incidence of paediatric emergence delirium. STUDY DESIGN The current study is a systematic review and network meta-analysis (NMA) of randomised controlled trials. DATA SOURCES We conducted a systematic search of 12 databases including Medline (Ovid) and Web of Science (Clarivate Analytics) from their respective inception to December 2020. ELIGIBILITY Inclusion criteria were randomised controlled trials of paediatric patients undergoing general anaesthesia using sevoflurane, sevoflurane with dexmedetomidine or TIVA. Data were extracted by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and analysed using NMA methodology. Risk ratios and 95% credible intervals (CrI) were calculated for all outcomes [emergence delirium, postoperative nausea and vomiting (PONV), and time to emergence and extubation]. The protocol was registered with PROSPERO (CRD42018091237). RESULTS The systematic review returned 66 eligible studies comprising 5257 patients with crude median emergence delirium incidences of 12.8, 9.1 and 40% in the dexmedetomidine with sevoflurane, TIVA and sevoflurane alone groups, respectively. NMA indicated that compared with TIVA, sevoflurane with adjuvant dexmedetomidine decreased the incidence of emergence delirium without statistical difference (risk ratio 0.88, 95% CrI 0.61 to 1.20, low quality of evidence), but resulted in a higher incidence of PONV (risk ratio: 2.3, 95% CrI 1.1 to 5.6, low quality of evidence). CONCLUSION Clinical judgement, considering the patient's risk factors for the development of clinically significant outcomes such as emergence delirium and PONV, should be used when choosing between TIVA and sevoflurane with adjuvant dexmedetomidine. These findings are limited by the low quality of evidence (conditional recommendation).

Global trends in research related to emergence delirium, 2012–2021: A bibliometric analysis

“…It can be seen that children, emergence delirium, dexmedetomidine, anesthesia, surgery, propofol and sevoflurane are the hot and key research areas in recent 10 years. Emergence delirium is a common complication in pediatric surgery and anesthesia ( Petre et al, 2021 ). Emergence delirium in children aged 2 to 12 years after general anesthesia is often reported in the literature, most of which have a short duration and are prone to contaminate the wound under the condition of unconsciousness, resulting in the removal of various drainage tubes and increasing the pressure of medical staff.…”

Incidence of Emergence Delirium in the Pediatric PACU: Prospective Observational Trial

“…Moreover, the evaluation of the scale is perceived by many anesthetists as complicated and lengthy. Another problem when evaluating ED by the PAED score arises from the use of different scales (a simplified version where only two or three characteristics are evaluated [ 17 ], as well as different cutoff values for ED diagnosis [ 18 , 19 ]. The maximum score is 20; according to the authors of the PAED scale, a cutoff of ≥10 points is positive for ED diagnosis [ 2 ].…”

“…However, when looking closely at the scale description, the child who is sleeping will score 12 points and therefore will falsely positively appear as ED-positive (the child makes eye contact with the caregiver—4 points, the child’s actions are purposeful—4 points, the child is aware of his/her surroundings—4 points, the child is restless—0 points, the child is inconsolable—0 points). In a few studies, the threshold was set even higher, to ≥16 points, but, in our opinion, this has no relevant justification [ 17 , 19 ]. The results of our study have shown a good correlation of the incidence of ED when using PAED >12 points, Watcha and RASS score, which could further justify the PAED cutoff >12 points.…”

“…In the case of the development of ED, the most-used drug for its treatment was propofol with a median dose of 0.83 mg/kg. Propofol appears to be effective for the treatment of ED, but the evidence for its beneficial effect is not entirely conclusive [ 11 , 19 ]. A recent meta-analysis from Wang et al suggests that a combination of pharmacologic therapies might be of greater effectiveness than monotherapy (e.g., combination of dexmedetomidine, midazolam and antiemetics or a combination of propofol, midazolam and antiemetics) [ 13 ].…”

“…A recent meta-analysis from Wang et al suggests that a combination of pharmacologic therapies might be of greater effectiveness than monotherapy (e.g., combination of dexmedetomidine, midazolam and antiemetics or a combination of propofol, midazolam and antiemetics) [ 13 ]. As monotherapy, dexmedetomidine, high-dose melatonin or nalbuphine showed good effects as well [ 13 , 19 , 28 ]. Dexmedetomidine in regular dosing does not cause respiratory centre depression, while having an effect as an anxiolytic, improving the child’s cognitive function and contributing to dose-dependent ED attenuation after general anesthesia [ 27 ].…”