FitzSimons James, Bonanno Laura S, Pierce Stephanie, Badeaux Jennifer
The Louisiana Centre for Promotion of Optimal Health Outcomes: a Joanna Briggs Institute Center of Excellence.
JBI Database System Rev Implement Rep. 2017 Jul;15(7):1934-1951. doi: 10.11124/JBISRIR-2016-003096.
Emergence delirium is defined as a cognitive disturbance during emergence from general anesthesia resulting in hallucinations, delusions and confusion manifested by agitation, restlessness, involuntary physical movement and extreme flailing in bed. Postoperative emergence delirium develops in 12% to 18% of all children undergoing general anesthesia for surgery. This post-anesthetic phenomenon changes cognitive and psychomotor behavior, and puts pediatric patients and health care personnel at risk of injury. A newer drug, dexmedetomidine, is a selective alpha-2 agonist, which works in the brain and spinal cord that has sedative, analgesic and anxiolytic properties. Dexmedetomidine also has the ability to lower the overall anesthetic requirements by reducing sympathetic outflow in response to painful surgical stimulation. In current literature, there is not a systematic review that compares the effectiveness of preoperative intranasal dexmedetomidine administration against oral midazolam for the prevention of emergence delirium.
The objective of this review was to identify the effectiveness of preoperative intranasal dexmedetomidine compared to oral midazolam for the prevention of emergence delirium in the pediatric patient undergoing general anesthesia.
This review considered studies that included pediatric patients aged three to seven years, with an American Society of Anesthesiologists (ASA) classification of I or II, and undergoing general anesthesia for elective/ambulatory surgery. This review excluded studies that included patients who had special needs including: developmental delay, chronic pain issues, and/or any preexisting mental or physical health disorders which categorized them above an ASA II.
TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: This review considered studies that compared preoperative intranasal administration of dexmedetomidine with preoperative oral administration of midazolam for the prevention of emergence delirium.
This review considered both experimental and non-experimental study designs including randomized-controlled trials (RCTs), non-randomized control trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies, and analytical cross-sectional studies for inclusion.
This review considered studies that included the presence of postoperative emergence delirium. Only studies that used the Pediatric Anesthesia Emergence Delirium Scale to quantify the degree of emergence delirium were included in the review. Adverse events other than emergence delirium were not considered as part of the outcomes inclusion criteria but were to be included in the discussion if any articles were identified.
The search strategy aimed to discover both published as well as unpublished studies. A three-step search strategy was utilized in eight databases. Studies published in English or with an English translation after 1999 were considered for inclusion in this review.
Assessment of methodological quality was not conducted as no studies were identified which met the inclusion criteria.
Data extraction and synthesis was not performed since no studies were included in this systematic review.
Following the three-step search strategy as previously described, 117 articles were identified: six in Clinical Trials, one in ProQuest, 14 in Ovid MEDLINE, 10 in CINAHL, 16 in the Cochrane Library, 13 in Scopus, 36 in Embase, and 21 in Web of Science. There were 43 duplicates which were identified and removed in Refworks by the primary reviewer. The primary and secondary reviewers independently retrieved 10 potentially relevant studies (from the initial 74) through title and abstract screening as described in the inclusion criteria. All of the retrieved studies were excluded, after assessment of full text, with reasons based on the inclusion criteria.
There is no scientific evidence identifying the effectiveness of preoperative intranasal dexmedetomidine, compared with oral midazolam, for the prevention of emergence delirium in the pediatric patient population.
苏醒期谵妄被定义为全身麻醉苏醒过程中的一种认知障碍，表现为幻觉、妄想和意识混乱，其特征为躁动、不安、不自主身体运动以及在床上剧烈挣扎。在所有接受全身麻醉手术的儿童中，术后苏醒期谵妄的发生率为12%至18%。这种麻醉后现象会改变认知和精神运动行为，并使儿科患者和医护人员面临受伤风险。一种较新的药物右美托咪定是一种选择性α-2激动剂，作用于大脑和脊髓，具有镇静、镇痛和抗焦虑特性。右美托咪定还能够通过减少对疼痛手术刺激的交感神经输出，降低总体麻醉需求。在当前文献中，尚无系统评价比较术前经鼻给予右美托咪定与口服咪达唑仑预防苏醒期谵妄的有效性。
本综述的目的是确定与口服咪达唑仑相比，术前经鼻给予右美托咪定预防接受全身麻醉的儿科患者苏醒期谵妄的有效性。
纳入标准 参与者类型：本综述纳入的研究包括年龄在3至7岁、美国麻醉医师协会（ASA）分级为I或II级、接受择期/门诊手术全身麻醉的儿科患者。本综述排除了包括有特殊需求患者的研究，这些特殊需求包括：发育迟缓、慢性疼痛问题和/或任何先前存在的精神或身体健康障碍（这些障碍将患者分类为ASA II级以上）。
干预类型/感兴趣的现象：本综述纳入的研究比较了术前经鼻给予右美托咪定与术前口服咪达唑仑预防苏醒期谵妄的效果。
本综述纳入了实验性和非实验性研究设计，包括随机对照试验（RCT）、非随机对照试验、准实验、前后对照研究、前瞻性和回顾性队列研究、病例对照研究以及分析性横断面研究。
本综述纳入的研究包括术后苏醒期谵妄的发生情况。本综述仅纳入了使用小儿麻醉苏醒期谵妄量表量化苏醒期谵妄程度的研究。除苏醒期谵妄外的不良事件不作为结局纳入标准的一部分，但如果发现有相关文章，则应在讨论中纳入。
检索策略旨在发现已发表和未发表的研究。在八个数据库中采用了三步检索策略。1999年以后发表的英文或有英文译文的研究被考虑纳入本综述。
由于未发现符合纳入标准的研究，因此未进行方法学质量评估。
由于本系统综述未纳入任何研究，因此未进行数据提取与综合。
按照上述三步检索策略，共识别出117篇文章：临床试验6篇、ProQuest数据库1篇、Ovid MEDLINE数据库14篇、CINAHL数据库10篇、Cochrane图书馆16篇、Scopus数据库13篇、Embase数据库36篇、Web of Science数据库21篇。主要审阅者在Refworks中识别并删除了43篇重复文章。主要和次要审阅者根据纳入标准，通过标题和摘要筛选，独立检索出10篇潜在相关研究（来自最初的74篇）。在全文评估后，所有检索到的研究均因不符合纳入标准而被排除。
尚无科学证据表明与口服咪达唑仑相比，术前经鼻给予右美托咪定对预防儿科患者群体的苏醒期谵妄有效。
