Meta-Analysis of Dexmedetomidine on Emergence Agitation and Recovery Profiles in Children after Sevoflurane Anesthesia: Different Administration and Different Dosage

<div><p>The objective of this article is to evaluate the effect of dexmedetomidine on emergence agitation (EA) and recovery profiles in children after sevoflurane anesthesia and its pharmacological mechanisms. Standard bibliographic databases, including MEDLINE, EMBASE, PsycINFP, Springer and ISI Web of Knowledge, were artificially searched to identify all randomized controlled trials (RCTs) comparing the impact of dexmedetomidine with placebo, fentanyl and midazolam on EA and recovery profiles after sevoflurane anesthesia in post-anesthesia care unit (PACU). Two authors assessed the quality of each study independently in accordance with strict inclusion criteria and extracted data. RevMan 5.0 software was applied for performing statistic analysis. The outcomes analyzed included: 1) incidence of EA, 2) emergence time, 3) time to extubation, 4) incidence of post-operation nausea and vomiting, 5) number of patients requiring an analgesic, and 6) time to discharge from PACU. A total of 1364 patients (696 in the dexmedetomidine group and 668 in the placebo, fentanyl and midazolam group) from 20 prospective RCTs were included in the meta-analysis. Compared with placebo, dexmedetomidine decreased the incidence of EA (risk ratio [RR] 0.37; 95% CI 0.30 to 0.46), incidence of nausea and vomiting (RR 0.57; 95% CI 0.38 to 0.85) and number of patients requiring an analgesic (RR 0.43; 95% CI 0.31 to 0.59). However, dexmedetomidine had a significantly delayed effect on the emergence time (weighted mean differences [WMD] 1.16; 95% CI 0.72 to 1.60), time to extubation (WMD 0.61; 95% CI 0.27 to 0.95), and time to discharge from recovery room (WMD 2.67; 95% CI 0.95 to 4.39). Compared with fentanyl (RR 1.39; 95% CI 0.78 to 2.48) and midazolam (RR 1.12; 95% CI 0.54 to 2.35), dexmedetomidine has no significantly difference on the incidence of EA. However, the analgesia effect of dexmedetomidine on postoperation pain has no significantly statistical differences compared with fentanyl (RR 1.12; 95% CI 0.66 to 1.91), which implied that its analgesia effect might play an important role in decreasing the incident of EA. No evidence of publication bias was observed.</p></div

Forest plot for the effect of different administration ways of dexmedetomidine on the incidence of EA.

<p>Forest plot for the effect of different administration ways of dexmedetomidine on the incidence of EA.</p

Forest plot for time to extubation.

<p>The plot displays the study, sample size, weighted mean differences (WMD), confidence interval, and P value. Meta-analysis indicates dexmedetomidine significant increased the time to extubation compared with the placebo group. The square shown for each study (first author and year of publication) is the mean difference for individual trials, and the corresponding horizontal line is the 95% CI. The diamond is the pooled WMD with the CI. The different sizes of squares indicate the weight the individual trials had in the analysis, talking into account sample size and standard deviations.</p

Forest plot for time to discharge from recovery room.

<p>The plot displays the study, sample size, weighted mean differences (WMD), confidence interval (CI), and P value. Meta-analysis indicates dexmedetomidine significant increase time to discharge from PACU compared with the placebo group. The square shown for each study (first author and year of publication) is the mean difference for individual trials, and the corresponding horizontal line is the 95% CI. The diamond is the pooled WMD with the CI. The different sizes of squares indicate the weight the individual trials had in the analysis, taking into account sample size and standard deviations</p

Statistics information of each analysis.

<p>Dex:dexmedetomidine; PACU: post-anesthesia care unit</p><p>Statistics information of each analysis.</p

Forest plot for emergence time.

<p>The plot displays the study, sample size, weighted mean differences (WMD), confidence interval (CI), and P value. Meta-analysis indicates dexmedetomidine significantly increased emergence time compared with the placebo group. The square shown for each study (first author and year of publication) is the mean difference for individual trials, and the corresponding horizontal line is the 95% CI. The diamond is the pooled WMD with the CI. The different sizes of squares indicate the weight the individual trials had in the analysis, talking into account sample size and standard deviations.</p

Forest plot for number of patients requiring analgesic dexmedetomidine vs Fentanyl and Bupivacaine.

<p>The plot displays the study, sample size, weighted risk ratio (RR), confidence interval (CI), and P value. Meta-analysis indicates the analgesia effect of dexmedetomidine on postoperation pain has no significantly statistical differences compared with fentanyl. The square shown for each study (first author and year of publication) is the RR for individual trials, and the corresponding horizontal line is the 95% CI. The diamond is the pooled RR with the CI. The different sizes of squares indicate the weight the individual trials had in the analysis, taking into account sample size.</p

The modified Jadad scores.

<p>The modified Jadad scores.</p

Forest plot for the incidence of EA.

<p>The plot displays the study, sample size, weighted risk ratio (RR), confidence interval (CI), and P value. Meta-analysis indicates dexmedetomidine significantly decreased the incidence of EA compared with placebo. The square shown for each study (first author and year of publication) is the RR for individual trials, and the corresponding horizontal line is the 95% CI. The diamond is the pooled RR with the CI. The different sizes of squares indicate the weight the individual trials had in the analysis, taking into account sample size.</p

Forest plot for the number of patients with post-operative nausea and vomiting.

<p>The plot displays the study, sample size, weighted risk ratio (RR), confidence interval (CI), and P value. Meta-analysis indicates dexmedetomidine significantly decrease the number of patients with post-operation nausea and vomiting compared with the placebo group. The square shown for each study (first author and year of publication) is the RR for individual trials, and the corresponding horizontal line is the 95% CI. The diamond is the pooled RR with the CI. The different sizes of squares indicate the weight the individual trials had in the analysis, taking into account sample size.</p