Background The present study with trial sequential analysis (TSA) was conducted to evaluate comprehensively the efficacy and safety of dexmedetomidine and midazolam in pediatric sedation, and to investigate whether the outcomes achieved the required information size to draw the conclusions. Methods PubMed, Embase, and Cochrane Library were searched from inception to October 2019. All randomized controlled trials used dexmedetomidine and midazolam in pediatric sedation were enrolled. Sedative efficacy, postoperative analgesic effect, and incidence of emergence agitation were considered as the co‐primary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to rate the quality of evidences. Results We acquired data from 34 studies involving 2281 pediatric patients. The results indicated that administration of dexmedetomidine was associated with less incidence of emergence agitation (RR = 0.78, with 95% CI [0.65, 0.92]) and more satisfactory sedation at parental separation (RR = 0.31, with 95% CI [0.24, 0.41]) compared to midazolam, and the current sample sizes were sufficient with unnecessary further trials. Two groups did not differ significantly in sedation level at mask induction (RR = 0.86, with 95% CI [0.74, 1.00]). And using of dexmedetomidine was associated with less incidence of postoperative analgesic rescue (RR = 0.57, with 95% CI [0.35, 0.93]), but the number of patients was too few to achieve the required information size and to draw reliable conclusions. Premedication of dexmedetomidine was associated with significant less value of SBP, heart rate, increased incidence of bradycardia, and a lower rate of shivering. And there were no differences about onset of sedation and recovery time between two groups. Conclusions Given that more satisfactory sedation at separation from parents and less incidence of emergence agitation, dexmedetomidine is preferred for pediatric sedation. However, compared with midazolam, the superiority of dexmedetomidine in providing adequate sedation at mask induction and postoperative analgesic effects has not yet been defined.

Background:Propofol injection pain was considered as one conundrum during clinical anesthesia. The systematic review about the effect of lidocaine in reducing injection pain among children has not been established. The aim of the study was to systematically evaluate the efficacy and safety of such intervention.Methods:The literature search was performed from the inception to the May 31, 2016 in PubMed, Ovid EMBASE, and Cochrane database. All randomized controlled trials that using lidocaine for propofol injection pain in children were enrolled. The primary outcome included the incidence of injection pain and the incidence of propofol injection pain in different degrees. The data were combined to calculate the relative ratio and relevant 95% confidence interval. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement.Results:Data from the included 11 studies indicated that the incidence of injection pain was lower in lidocaine group than the incidence in saline control group and in propofol lipuro (medium- and long-chain triglycerides) group (pain occurrence: 22.1% in lidocaine vs 66.8% in saline, RR with 95% 0.34 [0.26, 0.43], I2 = 38%; 30.5% in lidocaine vs 46.9% in propofol lipuro, RR with 95% 0.68 [0.46, 1.00], I2 = 9%). There was no difference between lidocaine and ketamine/alfentanil both in reducing pain occurrence and in reducing pain severity (pain occurrence: 29.7% in lidocaine vs 25.8% in ketamine, RR with 95% 1.47 [0.16, 13.43], I2 = 94%; 31.0% in lidocaine vs 30.7% in alfentanil, RR with 95% 1.01 [0.69, 1.46], I2 = 11%). And the reported side effects revealed that the safety of lidocaine in pediatric patients was acceptable.Conclusion:Compared with ketamine and alfentanil, lidocaine would be served as one more effective treatment in consideration of its well-matched efficacy, acceptable accessibility, and reasonable safety. However, more high-quality evidences in pediatric patients are necessary.

Background Intranasal midazolam and ketamine have been widely used as sedative premedication in children. It is difficult to determine which one yields better sedative effects for clinical practice. We conducted the present meta-analysis by summarizing the evidences to evaluate the efficacy and safety of intranasal midazolam versus intranasal ketamine as sedative premedication in pediatric patients. Methods We searched PubMed, Embase, and Cochrane Library from inception to April 2022. All randomized controlled trials (RCTs) used intranasal midazolam and ketamine as sedatives in children were enrolled. The risk of bias in RCTs was assessed by Cochrane risk of bias tool. Condition of parental separation, anesthesia induction or facemask acceptance, sedation level, different hemodynamic parameters and adverse events were considered as the outcomes in our study. Results A total of 16 studies with 1066 patients were enrolled. Compared with midazolam, administration of intranasal ketamine might be associated with severer changes in hemodynamics parameters including mean blood pressure (SMD = -0.53, with 95% CI [-0.93, -0.13]) and heart rate (HR) (SMD = -1.39, with 95% CI [-2.84, 0.06]). Meanwhile, administration of intranasal midazolam was associated with more satisfactory sedation level (61.76% vs 40.74%, RR = 1.53, with 95%CI [1.28, 1.83]), more rapid onset of sedation (SMD = -0.59, with 95%CI [-0.90, -0.28]) and more rapid recovery (SMD = -1.06, with 95%CI [-1.83, -0.28]). Current evidences also indicated that the differences of various adverse effects between two groups were not significant. Conclusions Given that administration of midazolam via intranasal route provides more satisfactory sedative level with less fluctuation of hemodynamics parameters and more rapid onset and recovery, it might be considered as the preferred sedative premedication for pediatric patients compared to ketamine. However, the widespread evidences with low or moderate quality indicated that superiority of intranasal midazolam in pediatric sedation needs to be confirmed by more studies with high quality and large sample size in future. Trial registration The protocol of present study was registered with PROSPERO (CRD42022321348).