Comparison of different sedatives in children before general anaesthesia for selective surgery: A network meta‐analysis

Abstract

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.

Pre-Admission Oral Clonidine to Reduce Severe Pre-Operative Anxiety in Pediatric Patients with Behavioral Disorders: A Case Series

“…Giving sedative medications like benzodiazepines at home carries the risk of airway obstruction, over-sedation, and respiratory depression when co-administered with perioperative opioids, especially in children with pre-existing diseases and syndromes. Clonidine is an effective pre-medication that may exhibit fewer respiratory concerns [ 1 , 2 , 3 ]. This is the first reported case series of pediatric patients receiving clonidine as a pre-admission premedication for the treatment of severe perioperative anxiety and/or behavioral concerns.…”

“…Preoperative anxiety is common in children, most commonly between ages 1–7 years, undergoing diagnostic and therapeutic procedures under anesthesia, and can lead to significant adverse effects, such as emergence delirium, increased analgesic doses in the recovery room, behavioral problems post-operatively, and post-traumatic stress disorder [ 1 ]. Several medication classes have been studied to treat anxiety and enhance cooperation in the pre-operative period, including benzodiazepines, ketamine, and alpha-2 adrenergic agonists.…”

“…Several medication classes have been studied to treat anxiety and enhance cooperation in the pre-operative period, including benzodiazepines, ketamine, and alpha-2 adrenergic agonists. There are advantages and disadvantages to each of these classes [ 1 , 2 ]. Clonidine, an alpha-2 adrenergic agonist, has many beneficial effects in the preoperative setting.…”

Histamine H1 receptor antagonist attenuates catecholamine surge and organ injury after severe burns

“…Fentanyl is an opioid analgesic like pethidine ( 20 ). Midazolam is a short-acting benzodiazepine, which has the effects of anti-anxiety, sedation, hypnosis, and muscle relaxation but with side effects such as respiratory depression ( 21 , 22 ). We find that promethazine-pethidine treatment showed a tendency for milder liver injury than midazolam-fentanyl in patients 7-day after severe burns.…”

A new view on old problems in paediatric anaesthesia: premedication, postoperative agitation and dosing

“…Drugs with α 2 -agonistic effects have played an essential role in veterinary anaesthesia for a long time; in humans, clonidine and dexmedetomidine are increasingly used for premedication, sedation or as co-analgesic compounds. Dexmedetomidine is considered to be a suitable [12 ▪ ] or even superior agent [13] for premedication compared with midazolam; this judgement was mainly based on the observation of more peaceful recovery and improved postoperative analgesia. However, recently two articles comparing midazolam with clonidine [7 ▪▪ ] and midazolam with clonidine and dexmedetomidine [8 ▪▪ ] showed that α 2 -agonists cause marked sedation, but virtually no anxiolysis.…”