Efficacy and Safety of Dexmedetomidine-Esketamine Versus Dexmedetomidine Alone as Premedication for Pediatric Anesthesia Induction: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis.

The potential benefits of using electroencephalography (EEG)-guided anesthesia for the prevention of emergence delirium in children remain unclear. To determine whether the intraoperative use of EEG-guided anesthesia is associated with a lower incidence of emergence delirium in pediatric patients. PubMed, Embase, and Cochrane databases were searched until July 2025. Searches followed PRISMA guidelines and were registered in PROSPERO. From 185 studies screened by 2 authors, 9 randomized clinical trials met the inclusion criteria: patients aged 1 to 18 years undergoing general anesthesia, comparing EEG-guided anesthesia with standard practice. Included studies reported at least 1 of the following outcomes: emergence delirium, pediatric anesthesia emergence delirium score, postanesthesia care unit length of stay, end-tidal sevoflurane concentration, or burst suppression. Data containing risk ratios (RRs) and mean differences (MDs) with 95% CIs were extracted from randomized clinical trials. Quality assessment and certainty of evidence were performed using the Risk of Bias 2 (RoB-2) tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, respectively. The primary outcome was the incidence of emergence delirium, a common postanesthesia psychomotor pediatric complication measured by pediatric anesthesia emergence delirium score greater than or equal to 10. This outcome was prespecified before data extraction and analysis. A total of 1052 patients from 9 included studies were included in this analysis, of whom 535 (50.9%) underwent EEG-guided anesthesia. The incidence of emergence delirium was significantly lower in the EEG-guided group compared with the standard-practice group (27% vs 48%; RR, 0.56; 95% CI, 0.37-0.84; P = .005). Maximum pediatric anesthesia emergence delirium scores (MD, -0.87; 95% CI, -1.52 to -0.23; P = .008), end-tidal sevoflurane concentration (MD, -0.40; 95% CI, -0.58 to -0.22; P <.001), and length of stay in the postanesthesia care unit (MD, -8.20; 95% CI, -13.35 to -3.04; P = .002) were also significantly lower in the EEG-guided anesthesia group. There was no statistically significant difference in the number of burst suppression episodes between the 2 groups (12% vs 17%; RR, 0.69; 95% CI, 0.42-1.12; P = .14). This systematic review and meta-analysis reveals that use of EEG-guided anesthesia was associated with a significantly lower risk of emergence delirium compared with standard practice in children.

Dexmedetomidine is being used increasingly as a premedicant in the paediatric population. However, the effectiveness of pre-operative intranasal dexmedetomidine premedication, compared with oral midazolam, for emergence delirium is not well characterised. To identify the effectiveness of pre-operative intranasal dexmedetomidine for emergence delirium in the paediatric patient population following general anaesthesia. A prospective, randomised, double-blind, parallel-group, placebo-controlled trial. Single university teaching hospital, from September 2013 to August 2014. One hundred and fifty-six patients undergoing anaesthesia for strabismus surgery were included in the study. Patients were randomised in a 1 : 1 : 1 ratio to receive premedication with intranasal dexmedetomidine 2 μg kg (the dexmedetomidine group), oral midazolam 0.5 mg kg (the midazolam group), or 0.9% saline (the placebo group). The primary outcome was the incidence of emergence delirium assessed by the Paediatric Anaesthesia Emergence Delirium scale. Secondary outcomes included the quality of the inhalational induction, emergence time, postoperative pain intensity, length of stay in the postanaesthesia care unit, the incidence of postoperative nausea or vomiting (PONV) and parents' satisfaction. The incidence of emergence delirium was lower in patients given dexmedetomidine compared with that in patients given midazolam (11.5 versus 44%, relative risk = 0.262, 95% confidence interval 0.116 to 0.592) or 0.9% saline (11.5 versus 49%, relative risk = 0.235, 95% confidence interval 0.105 to 0.525). Likewise, the incidence of PONV was lower in the dexmedetomidine group (3.8%) than that in the midazolam (22%; P = 0.006) or placebo (29.4%; P < 0.001) groups. However, there was no difference among the groups concerning postoperative pain scores and length of postanaesthesia care unit stay. In paediatric patients undergoing strabismus surgery intranasal dexmedetomidine 2 μg kg premedication decreases the incidence of emergence delirium and PONV, and improves parents' satisfaction compared with oral midazolam. ClinicalTrials.gov (identifier: NCT01895023).

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 18yr 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, -0.25mg·kg-1 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 0.5µg·kg-1 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; I2 = 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.

Emergence agitation or delirium can occur in pediatric patients after anesthesia. Dexmedetomidine is known to reduce the impairment of postoperative cognitive function. This study aimed to identify the role of intranasal administration of dexmedetomidine in lowering the development of emergence agitation or emergence delirium in pediatric patients after general anesthesia. Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. The primary outcome was the proportion of patients who underwent emergence agitation or emergence delirium after the surgery. Secondary outcomes included emergence time and incidence of postoperative nausea and/or vomiting. We estimated the odds ratio and mean difference with 95% confidence intervals for the determination of effect size using a random-effects model. In total, 2103 pediatric patients from 20 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 13.6% in the dexmedetomidine group and 33.2% in the control group. The pooled effect size revealed that intranasal dexmedetomidine administration significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery under general anesthesia (odds ratio 0.25, 95% confidence interval 0.18-0.34; p = .0000; I2 = 37.74%). Additionally, significant difference was observed in emergence time between the two groups (mean difference 2.42, 95% confidence interval 0.37-4.46; p = .021; I2 = 98.40%). Children in the dexmedetomidine group had a significantly lower incidence of postoperative nausea and/or vomiting than those in the control group (odds ratio 0.39, 95% confidence interval 0.24-0.64; p = .0002; I2 = 0.00%). Intranasal dexmedetomidine reduced the incidence of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

Background: Pre-operative anxiety in children not only makes induction difficult but it is also associated with an increase in the requirement of analgesics, the incidence of post-operative nausea and vomiting (PONV), emergence delirium (ED), and postoperative maladaptive behavioral changes. It can be reduced effectively by pharmacological interventions. In a quest to find the ideal premedicant and non-invasive way of its administration, we decided to compare intranasal (IN) dexmedetomidine with IN ketamine as a premedicant in pediatric patients.Aims and objectives: To compare sedation score, mask acceptance score (MAS) during induction, the incidence of ED, and other adverse events in both groups.Material and methods: Some 60 children, between 1 and 8 years of age of either sex undergoing surgical procedures were included in this study and randomly divided into two groups (Group D and Group K). Thirty minutes prior to induction of anesthesia, patients of Group D received dexmedetomidine 1 mcg kg-1 in 1 mL of 0.9% saline intranasally and patients of Group K received ketamine 5 mg kg-1 in 1 mL of 0.9% saline intranasally through calibrated dropper (0.5 mL in each nostril) in a recumbent position. Incidences of sneezing or coughing after IN administration of study drugs were recorded. The subsequent sedation scores were assessed using MOASS at 15 min, then at 30 min following premedication at the time of parental separation. After shifting patients to operation theater inhalation induction was done. MAS at induction and any adverse effects were recorded.Results: Children in Group K were found to be significantly more sedated at 30 min after administration of premedication and mask acceptance was also better (p value < 0.0001 with a confidence interval, CI=95%). But the incidence of ED and PONV was high.Conclusion: Intranasal dexmedetomidine (1 mcg kg-1) is clinically less effective as a premedicant in terms of sedation and mask acceptance in older children as compared to ketamine (5 mg kg-1), but associated with fewer incidence of ED and PONV. We recommend the usage of IN dexmedetomidine in a higher dose (1.5-2 mcg kg-1), through nebulization/atomizer for the desired level of sedation and mask acceptance.

Preoperative anxiety is a common problem in pediatric surgical patients and is a recognized predictor of emergence delirium (ED) and postoperative negative behavioral changes (PNBC). Intranasal premedication has emerged as a preferred route in children. Both dexmedetomidine and esketamine have demonstrated independent efficacy in this context. Their pharmacological complementarity has prompted growing interest in their combined use, yet no systematic review has comprehensively compared their efficacy and safety as monotherapies across pediatric procedural settings. This review aimed to evaluate and compare intranasal dexmedetomidine versus intranasal esketamine in pediatric patients. The study was conducted in accordance with the Cochrane Handbook and reported following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Five electronic databases were searched without date restriction. Risk of bias was assessed using the Cochrane RoB 2 tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale for the cohort study. Pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated using RevMan 5.4, with fixed- or random-effects models applied based on heterogeneity. The final analysis included five studies (four RCTs, one prospective cohort) with a combined sample of 481 pediatric participants. In elective surgical settings, dexmedetomidine at 2 µg/kg significantly reduced ED incidence compared to esketamine (RR 0.57 (0.38, 0.86); p=0.008) and was associated with significantly lower Pediatric Anesthesia Emergence Delirium (PAED) scale scores (MD -1.28 (-2.36, -0.20); p=0.02). Conversely, esketamine demonstrated significantly lower PAED scores in the bronchoscopy subgroup (MD 2.73 (1.84, 3.62); p<0.00001). Dexmedetomidine was also associated with significantly lower Face Legs Activity Cry Consolability (FLACC) pain scores in the emergency department subgroup (MD -3.25 (-5.64, -0.86); p=0.008). Regarding the primary endpoints, the overall pooled ED incidence did not differ significantly between agents (RR 0.77 (0.37, 1.62); p=0.49), nor did overall FLACC pain scores (MD -0.24 (-1.13, 0.65); p=0.60). Intranasal dexmedetomidine and esketamine demonstrate comparable overall efficacy and safety as pediatric premedication agents, with neither showing a significant pooled advantage over the other. However, their comparative performance is context- and dose-dependent, with dexmedetomidine at 2 µg/kg proving superior in elective surgical settings, and esketamine performing better in bronchoscopy procedures. These findings support individualized agent selection based on procedural context and dosing rather than a universal preference for either agent. Larger, standardized multicenter trials are needed to establish definitive evidence-based premedication recommendations across pediatric surgical settings.

BackgroundOperative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures.MethodsA systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research.ResultsFrom 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence.ConclusionMeta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients.Systematic review registration: UMIN Clinical Trials Registry UMIN000049365.

BackgroundThe evaluation of imprecision is a key dimension of the grading of the confidence in the estimate. Grading of Recommendations Assessment, Development and Evaluation (GRADE) gives recommendations on how to downgrade evidence for imprecision, but authors vary in their use. Trial Sequential Analysis (TSA) has been advocated for a more reliable assessment of imprecision. We aimed to evaluate reporting of and adherence to GRADE and to compare the assessment of imprecision of intervention effects assessed by GRADE and TSA in Cochrane systematic reviews.MethodsIn this cross-sectional study, we included 100 Cochrane reviews irrespective of type of intervention with a key dichotomous outcome meta-analyzed and assessed by GRADE. The methods and results sections of each review were assessed for adequacy of imprecision evaluation. We re-analyzed imprecision following the GRADE Handbook and the TSA Manual.ResultsOverall, only 13.0% of reviews stated the criteria they applied to assess imprecision. The most common dimensions were the 95% width of the confidence intervals and the optimal information size. Review authors downgraded 48.0% of key outcomes due to imprecision. When imprecision was re-analyzed following the GRADE Handbook, 64% of outcomes were downgraded. Agreement between review authors’ assessment and assessment by the authors of this study was moderate (kappa 0.43, 95% confidence interval [CI] 0.23 to 0.58). TSA downgraded 69.0% outcomes due to imprecision. Agreement between review authors’ GRADE assessment and TSA, irrespective of downgrading levels, was moderate (kappa 0.43, 95% CI 0.21 to 0.57). Agreement between our GRADE assessment following the Handbook and TSA was substantial (kappa 0.66, 95% CI 0.49 to 0.79).ConclusionsIn a sample of Cochrane reviews, methods for assessing imprecision were rarely reported. GRADE according to Handbook guidelines and TSA led to more severe judgment of imprecision rather than GRADE adopted by reviews’ authors. Cochrane initiatives to improve adherence to GRADE Handbook are warranted. TSA may transparently assist in such development.

Hydroxyethyl starch (HES) solutions have shown their efficiency for intravascular volume expansion. A safety recommendation limiting their use in adult patients has recently been made. To assess the efficacy and adverse effects of HES when administered intra-operatively to paediatric patients. Systematic review with meta-analyses. Data were analysed using classical mean differences [and their 95% confidence intervals (CIs)] and trial sequential analysis. A Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification was performed for all outcomes. Reviewers extracted valid data, including perioperative total fluid intakes, mortality, renal function, coagulation tests, blood loss and length of hospital and ICU stay. Searches were performed in databases (Pubmed, Embase, Cochrane central register of controlled trials), clinical trials register, and open access journals not indexed in major databases. Randomised controlled trials (RCTs) published before December 2016 involving paediatric patients who received 6% low molecular weight HES. Nine RCTs involving 530 peri-operative paediatric patients were analysed. Compared with other fluids, HES did not significantly modify the amount of peri-operative fluid administered [mean difference 0.04; 95% CI (-1.76 to 1.84) ml kg], urine output [mean difference -33; 95% CI (-104 to 38) ml kg] or blood loss [mean difference -0.09; (-0.32 to 0.15) ml kg]. Trial sequential analysis determined that the outcomes for peri-operative fluid and urine output were underpowered. All results were graded as very low quality of evidence. Intravascular volume expansion with low molecular weight 6% HES did not appear to modify renal function, blood loss or transfusion when administered to children during the peri-operative period. However, given the lack of statistical power and the very low GRADE quality of evidence, more high-quality RCTs are needed to explore these outcomes.

Bariatric surgery is effective for severe obesity, but recovery is often complicated by pain, nausea, and high opioid use. This systematic review and meta-analysis (SRMA) evaluates the role of erector spinae plane block (ESPB) in reducing pain, opioid consumption, and postoperative nausea and vomiting (PONV) after bariatric surgery. Electronic databases were systematically searched from their inception to March 2025 for randomized controlled trials (RCTs) assessing bilateral ESPB in adults undergoing bariatric surgery. This review included studies which compared ESPB to a control group and reported at least one postoperative outcome. The primary outcome was resting pain at 6h and 24h. The mean difference (MD) and 95% confidence interval (CI) were calculated for each study and pooled using a random-effects model. The meta-regression and trial sequential analysis were performed to evaluate the impact of confounding variables and sample size on the pooled estimate. The risk of bias and certainty of evidence were assessed using the Cochrane Risk of Bias 2 (RoB 2) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment tools. Twelve RCTs (n = 825; ESPB = 412, control = 413) were included. ESPB significantly reduced resting pain at 6h (MD: 1.79; 95% CI: 0.80 - 2.78; p = 0.0004) and 24h (MD: 1.09; 95% CI: 0.38-1.79; p = 0.002). Six RCTs (n = 509) reported lower movement-evoked pain at 6h (MD:1.28; 95% CI: 0.68-1.88; p < 0.0001) and 24h (MD: 0.79; 95% CI: 0.44-1.14; p < 0.0001). Nine RCTs (n = 673) showed reduced 24-h opioid consumption (MD: 9.0; 95% CI: 2.72 to 15.27, P = 0.005). Five RCTs (n = 448) reported a lower incidence of PONV with ESPB (Risk Ratio: 1.47; 95% CI: 1.08-1.98, p = 0.01). Meta-regression to adjust for baseline confounding factors and trial sequential analysis did not materially alter the results. The risk of bias was low, and the certainty of evidence was rated as moderate to low. This SRMA of RCTs demonstrates that ESPB may significantly reduce postoperative pain, 24-h postoperative opioid consumption, and PONV compared to control in patients undergoing bariatric surgery. However, further RCTs with adequate power, unified protocols, and clearly defined endpoints are warranted.

ObjectiveTo systematically evaluate the efficacy and safety of ozone autohemotherapy (O₃-AHT) in the treatment of zoster-associated pain (ZAP).MethodsPubMed, Cochrane Library, Web of Science, Embase, Chinese Biomedical Database, China National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP Database were searched on September 10, 2025. We searched for randomized controlled trials evaluating O₃-AHT for ZAP management from database inception to September 10, 2025. Two researchers independently screened the literature, extracted data, and assessed the risk of bias. Data analysis was performed using RevMan 5.4 and Stata 18.0 software to calculate the standardized mean difference (SMD), mean difference (MD), relative risk (RR), and their 95% confidence intervals (CI). Trial sequential analysis (TSA) was conducted using TSA 0.9.5.10 software to assess the robustness of the evidence, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the quality of evidence.ResultsA total of 20 studies involving 1,519 patients were included. Meta-analysis revealed that compared with the control group, O3-AHT significantly patient self-reported pain scores (visual analog scale [VAS] or numerical rating scale [NRS]) compared to controls (SMD = −1.77, 95% CI: −2.16 to −1.37, p < 0.01), improved the effective rate of pain relief (RR = 1.21, 95% CI: 1.09 to 1.33, p < 0.01), decreased inflammatory factor levels (e.g., IL-6: SMD = −1.84, 95% CI: −2.60 to −1.07, p < 0.01), and improved quality of life scores (MD = 0.75, 95% CI: 0.45 to 1.04, p < 0.01). No significant difference was observed in the incidence of adverse reactions between the two groups (RR = 0.77, 95% CI: 0.46 to 1.28, p = 0.31). However, substantial heterogeneity existed among studies (I2 often > 50%). TSA suggested that the current cumulative sample size exceeded the required information size for primary outcome (pain score), thereby supporting the reliability of the conclusion. GRADE evidence quality rating was very low to moderate, mainly limited by the risk of bias and heterogeneity of included studies.ConclusionO₃-AHT may effectively alleviate ZAP and improve the quality of life and sleep quality through anti-inflammatory and immunomodulatory mechanisms, with a favorable safety profile; moreover, combination therapy may offer greater clinical benefit. However, owing to limitations in the number and quality of included studies, further larger-scale, high-quality randomized controlled trials are warranted.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier: CRD420251145896.

BackgroundPediatric patients undergoing surgery frequently experience significant anxiety, which can result in adverse effects such as prolonged sedation and behavioral changes associated with pharmacological interventions such as oral midazolam. Video games offer a nonpharmacological distraction method that shows promise in alleviating procedural anxiety without significant adverse effects. However, the effectiveness of video games compared to midazolam in managing perioperative anxiety remains uncertain.ObjectiveThis study aimed to evaluate the effectiveness of video game interventions in reducing perioperative anxiety in pediatric patients undergoing general anesthesia.MethodsWe conducted a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by reference screening. Primary outcomes included anxiety levels assessed during parent separation and mask induction procedures, while secondary outcomes encompassed emergence delirium, postoperative behavior, and length of stay in the postanesthesia care unit (PACU). The risk of bias was assessed using the Risk of Bias 2 scale. Data were synthesized descriptively and through meta-analysis, with the certainty of the evidence evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.ResultsSix randomized controlled trials involving 612 participants were included in the analysis. Children who participated in video game interventions reported significantly lower anxiety levels during parent separation (standardized mean difference, SMD −0.31, 95% CI −0.50 to −0.12; P=.001), with high certainty, and during mask induction (SMD −0.29, 95% CI −0.52 to −0.05; P=.02), with moderate certainty, compared to those receiving oral midazolam. Additionally, significant differences in postoperative behavior changes in children were observed compared to oral midazolam (SMD −0.35, 95% CI −0.62 to −0.09; P=.008). Children in the video game intervention groups also had a shorter length of stay in the PACU (mean difference, MD −19.43 min, 95% CI −31.71 to −7.16; P=.002). However, no significant differences were found in emergence delirium (MD −2.01, 95% CI −4.62 to 0.59; P=.13).ConclusionsVideo game interventions were more effective than midazolam in reducing perioperative anxiety among pediatric patients, improving postoperative behavior, and shortening the length of stay in the PACU. However, video games alone did not outperform midazolam in managing emergence delirium. Further high-quality research is needed for more conclusive results.

BackgroundMidazolam is routinely used as preanesthetic medication in pediatric patients. Recently, dexmedetomidine has emerged as an alternative as a premedicant. We aimed to add more evidence about the efficacy and safety of two common routes of administration for pediatric premedication: oral midazolam versus intranasal dexmedetomidine. MethodsWe systematically searched Randomized Controlled Trials (RCTs) involving patients ≤ 18 years old undergoing preanesthetic medication and comparing intranasal dexmedetomidine with oral midazolam. Risk Ratio (RR) and Mean Difference (MD) with 95% Confidence Intervals (95% CI) were computed using a random effects model. Trial-sequential analyses were performed to assess inconsistency. ResultsSixteen RCTs (1,239 patients) were included. Mean age was 5.5 years old, and most procedures were elective. There was no difference in satisfactory induction or mask acceptance (RR = 1.15, 95% CI 0.97–1.37; p = 0.11). There was a higher incidence of satisfactory separation from parents in the dexmedetomidine group (RR = 1.40; 95% CI 1.13–1.74; p = 0.002). Dexmedetomidine was also associated with a reduction in the incidence of emergence agitation (RR = 0.35; 95% CI 0.14–0.88; p = 0.02). Heart rate and mean arterial pressure were marginally lower in the dexmedetomidine group but without clinical repercussions. ConclusionCompared with oral midazolam, intranasal dexmedetomidine demonstrated better separation from parents and lower incidence of emergence agitation in pediatric premedication, without a difference in satisfactory induction. Intranasal dexmedetomidine may be a safe and effective alternative to oral midazolam for premedication in pediatric patients.

Background: Pediatric anesthesia emergence delirium (PAED) is a common complication after general anesthesia, but its specific mechanism of occurrence is not yet clear. Sevoflurane is the most commonly used inhalation anesthetic drug for general anesthesia in children and its use may increase the risk of PAED. The utilization of electroencephalography (EEG) monitoring can permits anesthesiologists to titrate and achieve desired depth of anesthesia. Thus, the aim of this meta-analysis is to examine whether EEG-guided monitoring can reduce emergence delirium by reducing exposure to sevoflurane in pediatric patients undergoing elective non-cardiac surgery. Methods: A literature search for meta-analysis was performed using the PubMed, EMbase, Ovid Medline, Cochrane Library, WanFang Data and China National Knowledge Infrastructure (CNKI) databases for randomized controlled trial (RCT) until May 1, 2025 by two investigators who independently screened and reviewed studies for inclusion and performed data extraction. Our primary outcome was the average end-tidal sevoflurane concentration. The secondary outcomes were (1) incidence of emergence delirium; (2) incidence of burst suppression detected; (3) PAED total score; (4) time to extubation; (5) length of PACU stay. Heterogeneity was assessed by the I2 and chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data. The risk of bias was assessed using the Cochrane methodology. Meta-analysis was carried out by using RevMan 5.3 software. Results: Of 233 articles retrieved, 7 RCTs (involving 902 pediatric patients undergoing elective non-cardiac surgery) were included in the final analysis. Compare with standard anesthesia administration, the utilization of EEG-guided sevoflurane administration reduced the average end tidal sevoflurane concentration (MD= -0.90, 95% CI: -1.24~-0.57, P ＜ 0.00001) and incidence of emergence delirium (OR=2.73, 95% CI:1.80~4.14, P ＜0.00001) in pediatric patients. However, no diference was found in PAED total score (MD= 1.36, 95% CI: -1.34~4.15, P=0.34), incidence of burst suppression detected (OR=0.64, 95% CI:0.38~1.09, P=0.1), time to extubation (MD= -1.65, 95% CI: -4.65~1.25, P=0.26) and length of PACU stay (MD= -5.90, 95% CI: -12.27~0.47, P=0.07 ) between EEG-guided group and control group. Conclusions: In pediatric participants, EEG-guided monitoring of anesthesia depth and titrating the use of sevoflurane accordingly may reduce exposure of inhalation anesthetics and incidence of PAED. However, there is no evidence suggesting that sevoflurane titration guided by EEG has advantages in other outcome indicators in pediatric patients undergoing elective non-cardiac surgery. In the future, larger sample sizes and rigorously designed RCTs are still needed for further discussion. PROSPERO registration number: CRD420251046992

BackgroundSepsis is characterized by a complex immune response. This meta-analysis evaluated the clinical effectiveness of intravenous IgM-enriched immunoglobulin (IVIgGM) in patients with sepsis and septic shock.MethodsFour databases, PubMed, the Cochrane Library, the ISI Web of Knowledge, and Embase, were systematically searched from inception to June 2018 to update the 2013 edition of the Cochrane review by two investigators, who independently selected studies, extracted relevant data, and evaluated study quality. Data were subjected to a meta-analysis and trial sequential analysis (TSA) for the primary and secondary outcomes. Level of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale.ResultsNineteen studies comprising 1530 patients were included in this meta-analysis. Pooled analyses showed that the use of IVIgGM reduced the mortality risk of septic patients (relative risk 0.60; 95% confidence interval [CI] 0.52–0.69, I2 = 0%). TSA showed that IVIgGM had a significant effect on mortality. Additionally, the meta-analysis suggested that use of IVIgGM shortened length of mechanical ventilation (mean difference − 3.16 days; 95% CI − 5.71 to − 0.61 days) and did not shorten length of stay in the intensive care unit (mean difference − 0.38 days; 95% CI − 3.55 to 2.80 days). The GRADE scale showed that the certainty of the body of evidence was low for both benefits and IVIgGM.ConclusionAdministration of IVIgGM to adult septic patients may be associated with reduced mortality. Treatment effects tended to be smaller or less consistent when including only those studies deemed adequate for each indicator. The available evidence is not clearly sufficient to support the widespread use of IVIgGM in the treatment of sepsis.Trial registration PROSPERO registration number: CRD42018084120. Registered on 11 February 2018.