Preventing Emergence Agitation Using Ancillary Drugs with Sevoflurane for Pediatric Anesthesia: A Network Meta-Analysis.

Abstract

Using sevoflurane for pediatric anesthesia plays a pivotal role in surgeries. Emergence agitation (EA) is a major adverse event accompanied with pediatric anesthesia. Other anesthetic adjuvants can be combined with sevoflurane in clinical practices for different purposes. However, it is uncertain that such a practice may have substantial influence on the risk of EA. We conducted a literature search in online databases, including PubMed, Embase, Cochrane Library, and Clinical Trials. Key data were extracted from eligible randomized control trials (RCTs). Both pairwise and network meta-analysis (NMA) were conducted for synthesizing data from eligible studies. The relative risk of EA was assessed using the odds ratios (ORs) and their corresponding 95% confidence intervals (CI) or credible intervals (CrI). Ranking scheme based on the surface under the cumulative ranking curve (SUCRA) values was produced. Several key assumptions of NMA such as heterogeneity, degree of consistence, and publication bias were validated by different statistical or graphical approaches. Evidence from 67 randomized control trials was synthesized. The relative risk of EA associated with eight anesthetic adjuvants was analyzed, including ketamine, propofol, dexmedetomidine, clonidine, midazolam, fentanyl, remifentanil, and sufentanil. Patients with the following anesthetic adjuvants appeared to have significantly reduced risk of EA in relation to those with placebo: dexmedetomidine (OR=0.18, 95% CrI 0.12-0.25), fentanyl (OR=0.19, 95% CrI 0.12-0.30), sufentanil (OR=0.20, 95% CrI 0.08-0.50), ketamine (OR=0.21, 95% CrI 0.13-0.34), clonidine (OR=0.25, 95% CrI 0.14-0.46), propofol (OR=0.32, 95% CrI 0.18-0.56), midazolam (OR=0.46, 95% CrI 0.27-0.77), and remifentanil (OR=0.29, 95% CrI 0.13-0.68). The SUCRA values for each anesthetic adjuvant were: dexmedetomidine (73.65%), fentanyl (68.04%), sufentanil (60.81%), ketamine (59.99%), clonidine (47.74%), remifentanil (40.15%), propofol (33.23%), midazolam (16.33%), and placebo (0.06%). Incorporating anesthetic adjuvants particularly dexmedetomidine into sevoflurane appeared to be significantly associated with a decreased risk of EA in pediatric anesthesia.