Olsen Julia M, Sumie Makoto, Yang Alan, Englesakis Marina, Niimi Naoko, Campisi Paolo, Hayes Jason, Ng William C K, Maynes Jason T, Pechlivanoglou Petros, Aoyama Kazuyoshi
Department of Anesthesia and Pain Medicine, The Hospital for Sick Children (SickKids), Toronto, ON, Canada.
Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada.
Can J Anaesth. 2025 Jul 11. doi: 10.1007/s12630-025-02991-7.
We aimed to evaluate the effects of intravenous dexmedetomidine (DEX) on perioperative opioid requirements, and secondarily on perioperative respiratory adverse events (PRAE), emergence delirium (ED), and postoperative nausea and vomiting in pediatric patients undergoing tonsillectomy.
We conducted a systematic review with meta-analysis, searching seven databases up to 7 May 2024. We included randomized controlled trials of patients aged 18 yr or younger undergoing tonsillectomy, comparing intravenous DEX and opioids with opioids. Our primary outcome was perioperative opioid requirements, expressed as oral morphine equivalents (OME). The secondary outcomes included the incidences of perioperative respiratory adverse events (PRAE), emergence delirium (ED), and postoperative nausea and vomiting (PONV), We used the Cochrane Risk of Bias 2 tool and assessed the certainty of the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). We used a pairwise random effects model to compute the risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) of the effects of DEX on each outcome. To explore dose-dependent effects of DEX, we used a random effects meta-regression model.
We included 16 trials in our systematic review, of which we analyzed 7 for opioid requirements, 4 for PRAE, 3 for ED, and 12 for PONV. Dexmedetomidine was associated with lower perioperative opioid requirements (MD, -0.25 mg·kg OME; 95% CI, -0.36 to -0.13; moderate certainty), equivalent to a 40% relative reduction of perioperative OME, and a lower likelihood of ED (RR, 0.24; 95% CI, 0.08 to 0.71; moderate certainty). Despite DEX not having a dose-dependent effect on OME, the RR of ED decreased 87% for each 0.5 µg·kg increment in DEX dose. Dexmedetomidine did not reduce the incidence of sustained or severe cough as a part of PRAE, but it reduced PONV (RR, 0.48; 95% CI, 0.35 to 0.66; I = 0%; low certainty).
Dexmedetomidine may improve the perioperative course of children undergoing tonsillectomy by decreasing perioperative opioid requirements and dose-dependently lowering the incidence of ED. Limitations of the present systematic review with meta-analysis include an inconsistent definition of PRAE in trials and heterogeneity due to variability of observed effect sizes.
PROSPERO ( CRD42023392579 ); first submitted 1 July 2023.
我们旨在评估静脉注射右美托咪定（DEX）对小儿扁桃体切除患者围手术期阿片类药物需求量的影响，其次评估其对围手术期呼吸不良事件（PRAE）、苏醒期谵妄（ED）及术后恶心呕吐的影响。
我们进行了一项系统评价并荟萃分析，检索了截至2024年5月7日的七个数据库。我们纳入了18岁及以下接受扁桃体切除术患者的随机对照试验，比较静脉注射DEX与阿片类药物联用阿片类药物的效果。我们的主要结局是围手术期阿片类药物需求量，以口服吗啡当量（OME）表示。次要结局包括围手术期呼吸不良事件（PRAE）、苏醒期谵妄（ED）及术后恶心呕吐（PONV）的发生率。我们使用Cochrane偏倚风险2工具，并通过推荐分级的评估、制定与评价（GRADE）来评估证据的确定性。我们使用成对随机效应模型计算DEX对各结局影响的风险比（RRs）或平均差（MDs）及其95%置信区间（CIs）。为探究DEX的剂量依赖性效应，我们使用了随机效应元回归模型。
我们的系统评价纳入了16项试验，其中7项分析了阿片类药物需求量，4项分析了PRAE，3项分析了ED，12项分析了PONV。右美托咪定与较低的围手术期阿片类药物需求量相关（MD，−0.25 mg·kg OME；95% CI，−0.36至−0.13；中等确定性），相当于围手术期OME相对降低40%，且ED的发生可能性较低（RR，0.24；95% CI，0.08至0.71；中等确定性）。尽管DEX对OME没有剂量依赖性效应，但DEX剂量每增加0.5 μg·kg，ED的RR降低87%。右美托咪定并未降低作为PRAE一部分的持续性或严重咳嗽的发生率，但降低了PONV（RR，0.48；95% CI，0.35至0.66；I² = 0%；低确定性）。
右美托咪定可能通过降低围手术期阿片类药物需求量并剂量依赖性降低ED的发生率来改善小儿扁桃体切除患者的围手术期过程。本系统评价及荟萃分析的局限性包括试验中PRAE的定义不一致以及观察到的效应大小存在差异导致的异质性。
PROSPERO（CRD42023392579）；于2023年7月1日首次提交。
