Optimizing pediatric premedication for general anesthesia: A comprehensive Bayesian network meta-analysis

Area of Science:

• Pediatric Anesthesiology
• Pharmacology
• Evidence-Based Medicine

Background:

• Preoperative anxiety and fear are common in pediatric patients undergoing anesthesia.
• Effective premedication is crucial for improving patient cooperation and reducing distress during medical procedures.
• Optimizing premedication strategies can enhance the overall patient experience and procedural success.

Purpose of the Study:

• To systematically review and analyze randomized controlled trials to determine the most effective premedication strategies for pediatric patients.
• To identify optimal drug combinations, routes, doses, and timing for improving mask acceptance, parental separation, and intravenous cannulation acceptance.
• To provide evidence-based recommendations for preoperative care in pediatric anesthesia.

Main Methods:

• A systematic review and Bayesian network meta-analysis of 69 randomized controlled trials involving 5794 pediatric patients (aged 1-12 years, ASA I-III).
• Two analyses were performed: a primary analysis considering unique drug, dose, route, and timing combinations, and a secondary analysis grouping by pharmacological agent.
• Outcomes assessed included satisfactory acceptance of mask application, parental separation, and intravenous cannulation, with meta-regression and bias assessments.

Main Results:

• Combinations of dexmedetomidine, midazolam, and ketamine showed the highest efficacy for mask acceptance, particularly with intranasal administration at 15-30 minute intervals.
• The secondary analysis confirmed that dexmedetomidine- and midazolam-based combinations were most effective for mask, IV cannulation, and parental separation acceptance.
• Clonidine, melatonin, and diazepam were found to be less effective compared to the top-ranking combinations.

Conclusions:

• Dexmedetomidine-, midazolam-, and ketamine-based premedication combinations significantly enhance preoperative cooperation in pediatric patients.
• These strategies lead to higher success rates in mask acceptance, intravenous cannulation, and parental separation.
• The choice of route, dose, and timing of premedication are critical determinants of successful outcomes.