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Comparison of different sedatives in children before general anaesthesia for selective surgery: A network
Chuan-Qi Yang1, Kai-Hua Yu1, Rong-Rong Huang1
1The First Clinical Medical College of Lanzhou University, Lanzhou, China.
Insights
Dexmedetomidine is an effective sedative for children undergoing anesthesia, offering better sedation and fewer side effects than other options like midazolam or ketamine. It is particularly useful for reducing preoperative anxiety and emergence delirium.
Area of Science:
- Pediatric Anesthesiology
- Pharmacology
- Clinical Trials
Background:
- Preoperative anxiety affects 60% of children undergoing anesthesia, leading to adverse reactions.
- Several sedatives (dexmedetomidine, midazolam, clonidine, ketamine, melatonin) are used for premedication, but no consensus exists on the optimal choice.
- Children aged 1-7 years undergoing selective surgery are a key demographic for evaluating sedative efficacy.
Purpose of the Study:
- To conduct a network meta-analysis (NMA) evaluating various sedatives for preoperative anxiety in children.
- To compare the effectiveness and safety of dexmedetomidine, midazolam, clonidine, ketamine, and melatonin.
- To identify the optimal sedative for premedication in pediatric selective surgery.
Main Methods:
- Systematic retrieval of randomized clinical trials (RCTs) from major databases (PubMed, Embase, CENTRAL, Web of Science).
- Primary outcomes: satisfactory sedation at parent separation and mask acceptance.
- Secondary outcomes: added benefits and side effects; NMA conducted using R software.
Main Results:
- Dexmedetomidine, midazolam, clonidine, and ketamine were superior to placebo for satisfactory sedation.
- Melatonin showed no significant difference from placebo in sedation.
- Dexmedetomidine, ketamine, clonidine, and melatonin reduced emergence delirium; midazolam increased PACU stay.
Conclusions:
- Dexmedetomidine, particularly intranasal administration, is a promising option for pediatric premedication.
- It offers effective sedation, reduced emergence delirium, fewer side effects, and faster onset.
- While effective, midazolam, ketamine, and clonidine are associated with more side effects.
What Is Known And Objective:
It is estimated that 60% of children undergoing anaesthesia develop severe preoperative anxiety. The anxiety is associated with adverse reactions. Sedatives such as dexmedetomidine, midazolam, clonidine, ketamine, and melatonin can be used as premedication against preoperative anxiety. However, no consensus has been reached on the choice of pre-anaesthetic sedatives in children before selective surgery. Therefore, the current network meta-analysis (NMA) was carried out to evaluate different sedatives in children aged between 1 and 7 before general anaesthesia for selective surgery.
Methods:
Randomized clinical trials (RCTs) were retrieved from Pubmed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases from inception to October 22, 2021. Primary outcomes showed satisfactory sedation at parent separation and also at induction or mask acceptance. Secondary outcomes were those related to added benefits and side effects. The present NMA was conducted using the R software. Results of the study were reported as Relative Risk (RR) or Mean Difference (MD) at a 95% credible intervals (CrIs).
Results And Discussion:
A total of 48 trials were included in the present study. It was found that the effectiveness of dexmedetomidine, midazolam, clonidine, and ketamine were superior to that of placebo in satisfactory sedation at parent separation and induction or mask acceptance. There was no significant difference between melatonin and placebo in satisfactory sedation at induction or mask acceptance. Dexmedetomidine, ketamine, clonidine, and melatonin were superior to placebo in reducing emergence delirium (ED). In addition, midazolam prolonged the length of stay in the post anaesthesia care unit (PACU) as compared with placebo. Dexmedetomidine caused a significant reduction in systolic blood pressure (SBP) and heart rate (HR). Nevertheless, it was noted that the hemodynamic changes were roughly within safety limits.
What Is New And Conclusion:
It was evident that the studied drugs can provide effective sedation with exception of melatonin and placebo. However, it was found that midazolam, ketamine, and clonidine lead to several side effects. The findings of the present study supported that dexmedetomidine, especially intranasal administration, has potential in the optimal selection of the sedatives for premedication in children. This is because the drug has effective sedation, reduced incidence of ED, side effects, and onset time.
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