Hemodynamic Response to Tracheal Intubation Using Indirect and Direct Laryngoscopes in Pediatric Patients: A Systematic Review and Network Meta-Analysis.

Hemodynamic response, particularly increased heart rate (HR) and blood pressure, can occur during tracheal intubation and is an adverse event to be avoided. The aim of this study was to use a network meta-analysis (NMA) to develop a ranking of hemodynamic responses (HR and mean blood pressure, MBP) after intubation of indirect and direct laryngoscopes in pediatric patients. Studies were eligible for inclusion if they had a prospective randomized design, compared hemodynamic response (HR and MBP) to tracheal intubation between indirect and/or direct laryngoscopes, and were conducted in pediatric patients. The pooled difference between each intubation device's intubation time is expressed as a weighted mean difference (WMD) of a 95% confidence interval (CI). The intubation time of the device was evaluated using P-scores calculated from the network point estimates and standard errors. A random-effects model was used when pooling effect sizes. We also analyzed intubation time as a related factor to hemodynamic responses. From the electronic databases, we selected 16 trials for review. In a Macintosh-referenced analysis, Airtraq suppressed an increase of HR and MBP during tracheal intubation in pediatric patients significantly more than a Macintosh laryngoscope. (HR; WMD = -16.7, 95%CI -22.5 to -10.9, MBP; WMD = -8.57, 95%CI -10.9 to -6.27). Airtraq also topped the HR and MBP P-score rankings. The results of this study showed similar laryngoscopes in the top five rankings of P-scores (Airtraq, Coopdech video laryngoscope, Miller, C-MAC, Wis-Hipple) for HR and intubation time. We applied a network meta-analysis to create a consistent ranking of intubation devices that prevent hemodynamic changes during tracheal intubation in pediatric patients. In this NMA, Airtraq proved to be the best laryngoscope for preventing hemodynamic responses during tracheal intubation in pediatric patients. In the analysis of intubation time, Airtraq showed the shortest intubation time.