From the Department of Pediatric Anesthesia, Montreal Children's Hospital, McGill University, Montreal, Quebec (M-AP), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children (DNL, JTM, KA), Department of Anesthesiology and Pain Medicine, University of Toronto (DNL, JTM, KA), Library and Information Services, University Health Network (ME), Program in Molecular Medicine (JTM), and Program in Child Health Evaluative Sciences (PP, KA), SickKids Research Institute, Toronto, Ontario, Canada.
Eur J Anaesthesiol. 2021 Nov 1;38(11):1111-1123. doi: 10.1097/EJA.0000000000001490.
Emergence delirium is a common complication in paediatric anaesthesia associated with significant morbidity. Total intravenous anaesthesia (TIVA) and intra-operative dexmedetomidine as an adjuvant to sevoflurane anaesthesia can both reduce the incidence of emergence delirium compared with sevoflurane alone, but no studies have directly compared their relative efficacy.
The study objective was to compare the effects of TIVA and dexmedetomidine on the incidence of paediatric emergence delirium.
The current study is a systematic review and network meta-analysis (NMA) of randomised controlled trials.
We conducted a systematic search of 12 databases including Medline (Ovid) and Web of Science (Clarivate Analytics) from their respective inception to December 2020.
Inclusion criteria were randomised controlled trials of paediatric patients undergoing general anaesthesia using sevoflurane, sevoflurane with dexmedetomidine or TIVA. Data were extracted by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and analysed using NMA methodology. Risk ratios and 95% credible intervals (CrI) were calculated for all outcomes [emergence delirium, postoperative nausea and vomiting (PONV), and time to emergence and extubation]. The protocol was registered with PROSPERO (CRD42018091237).
The systematic review returned 66 eligible studies comprising 5257 patients with crude median emergence delirium incidences of 12.8, 9.1 and 40% in the dexmedetomidine with sevoflurane, TIVA and sevoflurane alone groups, respectively. NMA indicated that compared with TIVA, sevoflurane with adjuvant dexmedetomidine decreased the incidence of emergence delirium without statistical difference (risk ratio 0.88, 95% CrI 0.61 to 1.20, low quality of evidence), but resulted in a higher incidence of PONV (risk ratio: 2.3, 95% CrI 1.1 to 5.6, low quality of evidence).
Clinical judgement, considering the patient's risk factors for the development of clinically significant outcomes such as emergence delirium and PONV, should be used when choosing between TIVA and sevoflurane with adjuvant dexmedetomidine. These findings are limited by the low quality of evidence (conditional recommendation).
在小儿麻醉中，苏醒期谵妄是一种常见的并发症，与显著的发病率有关。全凭静脉麻醉（TIVA）和术中右美托咪定作为七氟醚麻醉的辅助剂，与单独使用七氟醚相比，都可以降低苏醒期谵妄的发生率，但没有研究直接比较它们的相对疗效。
本研究旨在比较 TIVA 和右美托咪定对小儿苏醒期谵妄发生率的影响。
本研究是一项对随机对照试验进行系统评价和网络荟萃分析（NMA）的研究。
我们对包括 Medline（Ovid）和 Web of Science（Clarivate Analytics）在内的 12 个数据库进行了系统检索，检索时间从各自的起点到 2020 年 12 月。
纳入标准为接受七氟醚、七氟醚加右美托咪定或 TIVA 全身麻醉的小儿患者的随机对照试验。两名评审员根据系统评价和荟萃分析的首选报告项目指南提取数据，并使用 NMA 方法进行分析。对所有结局（苏醒期谵妄、术后恶心和呕吐[PONV]、苏醒和拔管时间）进行风险比和 95%可信区间（CrI）计算。该方案在 PROSPERO（CRD42018091237）上进行了注册。
系统评价共返回 66 项符合条件的研究，共纳入 5257 例患者，其中右美托咪定联合七氟醚、TIVA 和七氟醚单独组的苏醒期谵妄发生率分别为 12.8%、9.1%和 40%。NMA 表明，与 TIVA 相比，七氟醚加辅助用右美托咪定降低了苏醒期谵妄的发生率，但差异无统计学意义（风险比 0.88，95%CrI 0.61 至 1.20，低质量证据），但 PONV 发生率更高（风险比：2.3，95%CrI 1.1 至 5.6，低质量证据）。
在选择 TIVA 和七氟醚加辅助用右美托咪定时，应根据患者发生临床显著结局（如苏醒期谵妄和 PONV）的风险因素，结合临床判断。这些发现受到证据质量低的限制（有条件推荐）。
