Dexmedetomidine versus ketofol effect on the incidence of emergence agitation associated with sevoflurane-based anesthesia in children undergoing orthopedic surgery

Effect of different intranasal dexmedetomidine doses on pediatric postoperative delirium and agitation: network meta-analysis

OBJECTIVES

Our research served to explore the influences of intranasal dexmedetomidine (DEX) at different doses on agitation, delirium, and other complications among children undergoing general anesthesia.

METHODS

A systematic search was executed in EMBASE, Cochrane Library, PubMed, and Web of Science, from the establishment of the database until February 12, 2024. The data analytics was implemented through R software and STATA version 16.0.

RESULTS

The final analysis incorporated 15 randomized controlled trials (RCTs) containing 1965 pediatric participants in total. The findings uncovered that relative to normal saline (NS), intranasal DEX at doses of 1 μg/kg [RR = 0.31, 95%CI = (0.17, 0.56)], 1.5 μg/kg [RR = 0.28, 95%CI = (0.09, 0.85)], and 2 μg/kg [RR = 0.18, 95%CI = (0.08, 0.36)] remarkably reduced the prevalence of post-anesthetic emergence agitation (EA) in children, with the 2 μg/kg dose demonstrating the highest effectiveness (SUCRA = 0.8997). Additionally, DEX at doses of 1 μg/kg [MD = -3.36, 95%CI = (-6.46, -0.44)] and 2 μg/kg [MD = -2.59, 95%CI = (-5.17, -0.32)] effectively reduced the Pediatric Anesthesia Emergence Delirium (PAED) score, with the 1 μg/kg dose ranking as the most efficacious according to SUCRA analysis (SUCRA = 0.8557).

CONCLUSIONS

DEX prominently reduces the prevalence of emergence agitation and delirium. At doses of 2 μg/kg and 1 μg/kg, DEX effectively lowers the incidence of EA and PAED scores.

IMPACT

Our research attempts to appraise the influence of discrepant doses of intranasal dexmedetomidine (DEX) on the incidence of postoperative agitation and delirium among children undergoing general anesthesia. The research elucidates the impact of various DEX doses on reducing postoperative agitation, PAED scores, and the need for postoperative analgesics, offering valuable guidance for selecting optimal dosing strategies in clinical practice. The research results support considering individual differences in children when choosing different doses of DEX to provide more suitable sedation and analgesia regimens, thereby improving postoperative recovery quality.

Comparison between dexmedetomidine and ketofol in the prevention of postoperative emergence delirium in pediatric patients undergoing orofacial cleft surgery: A randomized controlled trial

Background and Aims

Emergence delirium (ED) is a common postoperative complication in pediatric patients. To avoid postoperative ED, sedative medications have been utilized in addition to general anesthesia. In this study, the primary objective was to assess the incidence of postoperative emergence of delirium at 0-, 10-, 20-, 30-, and 60-min intervals. Secondary objective was to assess postoperative analgesia (0, 10, 20, 30, and 60 min) and hemodynamic parameters (mean arterial pressure, pulse, oxygen saturation).

Material and Methods

In this randomized controlled study, 105 American Society of Anesthesiologists I and II patients, aged between 3 months and 2 years, scheduled for orofacial cleft surgery were enrolled. Patients of group I received dexmedetomidine (0.3 μg/kg), group II received ketofol (a mixture of ketamine 0.25 mg/kg and propofol 1.0 mg/kg), and group III received normal saline 10 min before extubation. The incidence of postoperative ED using the Watcha scale and the postoperative pain using the Face, Legs, Activity, Cry, Consolability (FLACC) scale were recorded.

Results

The Watcha scale at the immediate postoperative period and at 10-, 20-, 30-, and 60-min intervals was 0 (1), 1 (1.75), 1 (1), 2 (2), and 3 (2) in group I, 1 (1), 2 (1), 2 (2), 2 (3), and 3 (2) in group II, and 2 (1), 3 (1), 3 (1.25), 4 (1), and 4.5 (1.5) in group III, respectively, at the above time points. On comparing group I with groups II and III, the difference was significant (P < 0.01). The FLACC score at the immediate postoperative period and at 10-, 20-, 30-, and 60-min intervals was 1 (1), 1 (1), 1 (1), 2 (2), and 3 (2) in group I, 2 (2), 2 (1), 2 (2), 2(3), and 3 (2) in group II, and 4 (1), 3 (1), 3 (1.25), 4 (1), and 4.5 (1.5) in group III, respectively, at the above time points. The FLACC score was also lower in group I in comparison to groups II and III. The difference among the groups was significant (P < 0.01). The incidence of postoperative delirium was lower in group I at 20% (7/35) than in group II at 29% (10/35) and in group III at 49% (17/35), and difference among the groups was significant (<0.01).

Conclusions

We conclude that both dexmedetomidine and ketofol are effective in reducing postoperative ED. Dexmedetomidine is more effective than ketofol in preventing postoperative ED in the pediatric population.

Effects of different doses of intranasal dexmedetomidine on related complications and parents' satisfaction in anesthetized children: a systematic review

BACKGROUND

Agitation/delirium is commonly seen in children after anesthesia, and a proper dose of dexmedetomidine can prevent this complication. This study aimed to investigate the effects of different doses of Dexmedetomidine (DEX) on agitation/delirium and other complications in anesthetized children, providing clinical evidence for dose recommendations of DEX.

METHODS

This study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search was conducted in the Cochrane Library, PubMed, Web of Science, and EMBASE. Two independent researchers performed literature screening, data extraction, and assessed the methodological quality. Data analysis was conducted using R and STATA 16.0.

RESULTS

In the final analysis, 20 randomized controlled trials (RCTs) involving 2521 children were included. The results showed that in comparison to normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX significantly reduced the incidence of post-anesthetic emergence agitation in children with the most effective dose being 2 µg/kg (SUCRA = 0.91). Compared with normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX reduced patient's need for postoperative analgesia, with the most effective dose being 1.5 µg/kg (SUCRA = 0.78). However, 1 µg/kg DEX performed the best in reducing Pediatric Anaesthesia Emergence Delirium (PAED) Scale score (SUCRA = 0.88).

CONCLUSION

Compared with normal saline, intranasal administration of 2 µg/kg DEX and 1.5 µg/kg DEX are the optimal doses to reduce the incidence of agitation and the need for postoperative pain relief in children under general anesthesia. Given effectiveness and safety, intranasal use of 1 µg/kg DEX appears to be the most effective dosage for anesthetized children.

Ketofol versus Dexmedetomidine for preventing postoperative delirium in elderly patients undergoing intestinal obstruction surgeries: a randomized controlled study

PURPOSE

Postoperative delirium (POD) is considered the most common postoperative neurological complication in elderly patients. The aim of this study was to evaluate the efficacy of the administration of ketofol versus dexmedetomidine (DEX) for minimizing POD in elderly patients undergoing urgent exploration for intestinal obstruction.

METHODS

This prospective double-blinded randomized clinical trial was conducted on 120 elderly patients undergoing urgent exploration for intestinal obstruction. Patients were randomly allocated to one of the three groups: Group C (control group) patients received normal saline 0.9%, group D received dexmedetomidine, and group K received ketofol (ketamine: propofol was 1:4). The primary outcome was the incidence of POD. Secondary outcomes were incidence of emergence agitation, postoperative pain, consumption of rescue opioids, hemodynamics, and any side effects.

RESULTS

The incidence of POD was statistically significantly lower in ketofol and DEX groups than in the control group at all postoperative time recordings. Additionally, VAS scores were statistically significantly decreased in the ketofol and DEX groups compared to the control group at all time recordings except at 48 and 72 h postoperatively, where the values of the three studied groups were comparable. The occurrence of emergence agitation and high-dose opioid consumption postoperatively were found to be significant predictors for the occurrence of POD at 2 h and on the evening of the 1st postoperative day.

CONCLUSION

The administration of ketofol provides a promising alternative option that is as effective as DEX in reducing the incidence of POD in elderly patients undergoing urgent exploration for intestinal obstruction.

TRIAL REGISTRATION

This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZU-IRB# 6704// 3/03/2021) and ClinicalTrials.gov (NCT04816162, registration date 22/03/ 2021). The first research participant was enrolled on 25/03/2021).

Protective Effects of Dexmedetomidine on Hippocampal Neurons in Rats Anesthetized with Sevoflurane

To explore effects of dexmedetomidine (Dex) on cognitive function and hippocampal neuronal apoptosis in rats anesthetized with sevoflurane (Sevo), and regulation of brain-derived neurotrophic factor (BDNF) and its downstream signaling. 30 Sprague-Dawley (SD) rats were randomly divided into control group inhaled 29% concentration oxygen), Sevo group (2 L/min oxygen flow +1.5% Sevo), Dex+Sevo group (after injection of 20 μg/kg Dex, treated with 2L/min oxygen flow+1.5% Sevo). Haematoxylin and eosin (HE) staining and Nissl’s staining were adopted to detect morphological and functional changes in hippocampus of rats. Apoptosis was detected by immunofluorescence, BDNF expression was detected by immunohistochemistry. Reverse transcription PCR (RT-PCR) was conducted to detect mRNA expression of key proteins in downstream signaling of BDNF. The results showed that Sevo induced apoptosis of hippocampus neurons, while Dex improved Sevo induced apoptosis. In contrast to the control, the positive expression of BDNF in hippocampus of Sevo group was notably decreased (P < 0.05), and that of Dex+Sevo group was notably higher in contrast to Sevo group (P < 0.05). Signaling pathways of MAPK, PI3K-Akt, and Ras were predicted by String software as the downstream pathways of BDNF. RT-PCR results showed that these 3 signaling pathways were involved in Dex improving Sevo-induced cognitive impairment and hippocampal neuron apoptosis. In conclusion, Dex could improve cognitive dysfunction and hippocampal neuron apoptosis in rats induced by Sevo, and the mechanism was related to upregulation of BDNF expression and activation of pathways of MAPK, PI3K-Akt, and Ras.

Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis

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).

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.

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.