Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada.
Anesthesia & Perioperative Medicine, London Health Sciences Centre Children's Hospital, London, Ontario, Canada.
Reg Anesth Pain Med. 2021 May;46(5):422-432. doi: 10.1136/rapm-2020-102024. Epub 2021 Jan 15.
Dexmedetomidine is used as a local-anesthetics adjuvant in caudal block to prolong analgesia in pediatric infra-umbilical surgery.
We evaluated the analgesic efficacy and safety of the addition of caudal dexmedetomidine to local anesthetics (vs local anesthetics alone) in pediatric infra-umbilical surgery.
We searched 10 databases for randomized controlled trials (RCTs) of pediatric patients undergoing infra-umbilical surgery, comparing caudal block with and without dexmedetomidine as local anesthetic adjuvant. We performed a frequentist random-effects meta-analysis (R statistical package). We analyzed continuous outcomes as a ratio of means (ROM) and dichotomous data as relative risk (RR), along with 95% CI. We included 19 RCTs (n=1190 pediatric patients) in the meta-analysis. The primary outcome was duration of analgesia (defined as 'the time from caudal injection to the time at which the study-specific pain score was greater than a cut-off threshold').
Data from 19 included RCTs (n=1190) suggested that compared with control (mean duration 346 min), the addition of caudal dexmedetomidine significantly prolonged the duration of analgesia (ratio of means 2.14, 95% CI 1.83 to 2.49, p<0.001; 'moderate' evidence). Trial-sequential analysis showed adequate 'information size' for the primary outcome. Caudal dexmedetomidine also reduced the number of analgesic administrations ('low' evidence), total acetaminophen dose ('moderate' evidence) and the risk of emergence delirium ('moderate' evidence). There were no significant differences in adverse effects such as hypotension, bradycardia, post-operative nausea and vomiting, urinary retention and respiratory depression.
Our results suggest that the addition of dexmedetomidine to local anesthetic in caudal block significantly improves the duration of analgesia and reduces the analgesic requirements, while maintaining a similar risk-profile compared with local anesthetic alone. Further data on neurological safety are needed.
右美托咪定被用作骶管阻滞的局部麻醉剂佐剂，以延长小儿下腹部手术的镇痛时间。
我们评估了在小儿下腹部手术中骶管内加入右美托咪定（与单独使用局部麻醉剂相比）的镇痛效果和安全性。
我们在 10 个数据库中搜索了小儿下腹部手术的随机对照试验（RCT），比较了骶管阻滞加用和不加用右美托咪定作为局部麻醉剂佐剂的情况。我们进行了固定效应随机效应荟萃分析（R 统计软件包）。我们分析了连续结果作为均数比（ROM）和二分类数据作为相对风险（RR），并给出了 95%CI。我们纳入了 19 项 RCT（n=1190 例小儿患者）进行荟萃分析。主要结局是镇痛持续时间（定义为“从骶管注射到研究特定疼痛评分大于截断阈值的时间”）。
来自 19 项纳入 RCT 的数据（n=1190）表明，与对照组（平均持续时间 346 分钟）相比，骶管内加入右美托咪定显著延长了镇痛持续时间（均数比 2.14，95%CI 1.83 至 2.49，p<0.001；“中度”证据）。试验序贯分析显示主要结局的“信息大小”足够。骶管内加入右美托咪定还减少了镇痛药物的使用次数（“低”证据）、总对乙酰氨基酚剂量（“中度”证据）和谵妄发生率（“中度”证据）。低血压、心动过缓、术后恶心和呕吐、尿潴留和呼吸抑制等不良反应无显著差异。
我们的结果表明，与单独使用局部麻醉剂相比，骶管阻滞中加入右美托咪定可显著延长镇痛时间，减少镇痛需求，同时保持与单独使用局部麻醉剂相似的风险特征。需要进一步的数据来评估神经安全性。
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