Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis

Hung Yu Wang; Tien Yu Chen; Dian Jeng Li; Pao Yen Lin; Kuan Pin Su; Min Hsien Chiang; Andre F. Carvalho; Brendon Stubbs; Yu Kang Tu; Yi Cheng Wu; Michael Roerecke; Lee Smith; Ping Tao Tseng; Kuo Chuan Hung

doi:10.1016/j.jclinane.2021.110488

Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis

Hung Yu Wang, Tien Yu Chen, Dian Jeng Li, Pao Yen Lin, Kuan Pin Su, Min Hsien Chiang, Andre F. Carvalho, Brendon Stubbs, Yu Kang Tu, Yi Cheng Wu, Michael Roerecke, Lee Smith, Ping Tao Tseng^*, Kuo Chuan Hung

^*Corresponding author for this work

Research output: Contribution to journal › Review article › peer-review

29 Citations (Scopus)

Abstract

Study objective: This updated network meta-analysis aims at exploring whether the concurrent use of midazolam or antiemetics may enhance the efficacy of other pharmacological regimens for delirium prophylaxis in pediatric population after general anesthesia (GA). Design: Network meta-analysis (PROSPERO registration: CRD42020179483). Setting: Postoperative recovery area. Patients: Pediatric patients undergoing GA with sevoflurane. Interventions: Pharmacological interventions applied during GA with sevoflurane. Measurements: This network meta-analysis of randomized controlled trials (RCTs) was conducted with a frequentist model. PubMed, Embase, ProQuest, ScienceDirect, Cochrane CENTRAL, ClinicalKey, Web of Science, and ClinicalTrials.gov were searched from their inception dates to April 12, 2020, for RCTs of either placebo-controlled or active-controlled design containing information on the incidence of emergence delirium in pediatric patients undergoing sevoflurane anesthesia. Main results: Seventy studies comprising 6904 participants were included for the analysis of 30 pharmacological interventions. Based on surface under the cumulative ranking curve (SUCRA) analysis, midazolam was ranked the lowest in therapeutic effect (SUCRA: 20%), while antiemetics as a monotherapy had no effect on delirium prophylaxis. However, there was a trend that most combination therapies with midazolam or antiemetics were superior to monotherapies for delirium prophylaxis. Subgroup analyses based on age (i.e., ≤7 years) and a validated scoring system (i.e., the Pediatric Anesthesia Emergence Delirium scale) for delirium also suggested a better efficacy of combination therapies than monotherapies. Overall, combination therapies with midazolam or antiemetics did not have a negative impact on the incidence of postoperative nausea and vomiting, length of stay in the postanesthesia care unit, or time to extubation. The dexmedetomidine-midazolam-antiemetic combination was the most effective strategy for the prevention of emergence delirium. Conclusions: This network meta-analysis suggested that the incorporation of midazolam or antiemetics as adjuncts for combination therapies may have synergistic effects against pediatric postoperative emergence delirium. Future large-scale placebo-controlled RCTs are warranted to validate our findings.

Original language	English
Article number	110488
Journal	Journal of clinical anesthesia
Volume	75
DOIs	https://doi.org/10.1016/j.jclinane.2021.110488
Publication status	Published - Dec 2021

Keywords

Combination therapy
Emergence delirium
Network meta-analysis
Pediatric anesthesia
Sevoflurane

Access to Document

10.1016/j.jclinane.2021.110488

Cite this

Wang, H. Y., Chen, T. Y., Li, D. J., Lin, P. Y., Su, K. P., Chiang, M. H., Carvalho, A. F., Stubbs, B., Tu, Y. K., Wu, Y. C., Roerecke, M., Smith, L., Tseng, P. T., & Hung, K. C. (2021). Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis. Journal of clinical anesthesia, 75, Article 110488. https://doi.org/10.1016/j.jclinane.2021.110488

@article{f0fda85d9def4f31ad153653065e5cad,

title = "Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis",

abstract = "Study objective: This updated network meta-analysis aims at exploring whether the concurrent use of midazolam or antiemetics may enhance the efficacy of other pharmacological regimens for delirium prophylaxis in pediatric population after general anesthesia (GA). Design: Network meta-analysis (PROSPERO registration: CRD42020179483). Setting: Postoperative recovery area. Patients: Pediatric patients undergoing GA with sevoflurane. Interventions: Pharmacological interventions applied during GA with sevoflurane. Measurements: This network meta-analysis of randomized controlled trials (RCTs) was conducted with a frequentist model. PubMed, Embase, ProQuest, ScienceDirect, Cochrane CENTRAL, ClinicalKey, Web of Science, and ClinicalTrials.gov were searched from their inception dates to April 12, 2020, for RCTs of either placebo-controlled or active-controlled design containing information on the incidence of emergence delirium in pediatric patients undergoing sevoflurane anesthesia. Main results: Seventy studies comprising 6904 participants were included for the analysis of 30 pharmacological interventions. Based on surface under the cumulative ranking curve (SUCRA) analysis, midazolam was ranked the lowest in therapeutic effect (SUCRA: 20%), while antiemetics as a monotherapy had no effect on delirium prophylaxis. However, there was a trend that most combination therapies with midazolam or antiemetics were superior to monotherapies for delirium prophylaxis. Subgroup analyses based on age (i.e., ≤7 years) and a validated scoring system (i.e., the Pediatric Anesthesia Emergence Delirium scale) for delirium also suggested a better efficacy of combination therapies than monotherapies. Overall, combination therapies with midazolam or antiemetics did not have a negative impact on the incidence of postoperative nausea and vomiting, length of stay in the postanesthesia care unit, or time to extubation. The dexmedetomidine-midazolam-antiemetic combination was the most effective strategy for the prevention of emergence delirium. Conclusions: This network meta-analysis suggested that the incorporation of midazolam or antiemetics as adjuncts for combination therapies may have synergistic effects against pediatric postoperative emergence delirium. Future large-scale placebo-controlled RCTs are warranted to validate our findings.",

keywords = "Combination therapy, Emergence delirium, Network meta-analysis, Pediatric anesthesia, Sevoflurane",

author = "Wang, {Hung Yu} and Chen, {Tien Yu} and Li, {Dian Jeng} and Lin, {Pao Yen} and Su, {Kuan Pin} and Chiang, {Min Hsien} and Carvalho, {Andre F.} and Brendon Stubbs and Tu, {Yu Kang} and Wu, {Yi Cheng} and Michael Roerecke and Lee Smith and Tseng, {Ping Tao} and Hung, {Kuo Chuan}",

note = "Funding Information: The authors of this work were supported by the following grants: Brendon Stubbs is supported by a Clinical Lectureship ( ICA-CL-2017-03-001 ) jointly funded by Health Education England (HEE) and the National Institute for Health Research (NIHR) . Brendon Stubbs is part funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust . Brendon Stubbs is also supported by the Maudsley Charity , King's College London and the NIHR South London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) funding. This paper presents independent research. The views expressed in this publication are those of the authors and not necessarily those of the acknowledged institutions. Publisher Copyright: {\textcopyright} 2021 Elsevier Inc. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.",

year = "2021",

month = dec,

doi = "10.1016/j.jclinane.2021.110488",

language = "English",

volume = "75",

journal = "Journal of clinical anesthesia",

issn = "0952-8180",

publisher = "Elsevier",

}

Wang, HY, Chen, TY, Li, DJ, Lin, PY, Su, KP, Chiang, MH, Carvalho, AF, Stubbs, B, Tu, YK, Wu, YC, Roerecke, M, Smith, L, Tseng, PT & Hung, KC 2021, 'Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis', Journal of clinical anesthesia, vol. 75, 110488. https://doi.org/10.1016/j.jclinane.2021.110488

TY - JOUR

T1 - Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia

T2 - An updated network meta-analysis

AU - Wang, Hung Yu

AU - Chen, Tien Yu

AU - Li, Dian Jeng

AU - Lin, Pao Yen

AU - Su, Kuan Pin

AU - Chiang, Min Hsien

AU - Carvalho, Andre F.

AU - Stubbs, Brendon

AU - Tu, Yu Kang

AU - Wu, Yi Cheng

AU - Roerecke, Michael

AU - Smith, Lee

AU - Tseng, Ping Tao

AU - Hung, Kuo Chuan

N1 - Funding Information: The authors of this work were supported by the following grants: Brendon Stubbs is supported by a Clinical Lectureship ( ICA-CL-2017-03-001 ) jointly funded by Health Education England (HEE) and the National Institute for Health Research (NIHR) . Brendon Stubbs is part funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust . Brendon Stubbs is also supported by the Maudsley Charity , King's College London and the NIHR South London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) funding. This paper presents independent research. The views expressed in this publication are those of the authors and not necessarily those of the acknowledged institutions. Publisher Copyright: © 2021 Elsevier Inc. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

PY - 2021/12

Y1 - 2021/12

N2 - Study objective: This updated network meta-analysis aims at exploring whether the concurrent use of midazolam or antiemetics may enhance the efficacy of other pharmacological regimens for delirium prophylaxis in pediatric population after general anesthesia (GA). Design: Network meta-analysis (PROSPERO registration: CRD42020179483). Setting: Postoperative recovery area. Patients: Pediatric patients undergoing GA with sevoflurane. Interventions: Pharmacological interventions applied during GA with sevoflurane. Measurements: This network meta-analysis of randomized controlled trials (RCTs) was conducted with a frequentist model. PubMed, Embase, ProQuest, ScienceDirect, Cochrane CENTRAL, ClinicalKey, Web of Science, and ClinicalTrials.gov were searched from their inception dates to April 12, 2020, for RCTs of either placebo-controlled or active-controlled design containing information on the incidence of emergence delirium in pediatric patients undergoing sevoflurane anesthesia. Main results: Seventy studies comprising 6904 participants were included for the analysis of 30 pharmacological interventions. Based on surface under the cumulative ranking curve (SUCRA) analysis, midazolam was ranked the lowest in therapeutic effect (SUCRA: 20%), while antiemetics as a monotherapy had no effect on delirium prophylaxis. However, there was a trend that most combination therapies with midazolam or antiemetics were superior to monotherapies for delirium prophylaxis. Subgroup analyses based on age (i.e., ≤7 years) and a validated scoring system (i.e., the Pediatric Anesthesia Emergence Delirium scale) for delirium also suggested a better efficacy of combination therapies than monotherapies. Overall, combination therapies with midazolam or antiemetics did not have a negative impact on the incidence of postoperative nausea and vomiting, length of stay in the postanesthesia care unit, or time to extubation. The dexmedetomidine-midazolam-antiemetic combination was the most effective strategy for the prevention of emergence delirium. Conclusions: This network meta-analysis suggested that the incorporation of midazolam or antiemetics as adjuncts for combination therapies may have synergistic effects against pediatric postoperative emergence delirium. Future large-scale placebo-controlled RCTs are warranted to validate our findings.

AB - Study objective: This updated network meta-analysis aims at exploring whether the concurrent use of midazolam or antiemetics may enhance the efficacy of other pharmacological regimens for delirium prophylaxis in pediatric population after general anesthesia (GA). Design: Network meta-analysis (PROSPERO registration: CRD42020179483). Setting: Postoperative recovery area. Patients: Pediatric patients undergoing GA with sevoflurane. Interventions: Pharmacological interventions applied during GA with sevoflurane. Measurements: This network meta-analysis of randomized controlled trials (RCTs) was conducted with a frequentist model. PubMed, Embase, ProQuest, ScienceDirect, Cochrane CENTRAL, ClinicalKey, Web of Science, and ClinicalTrials.gov were searched from their inception dates to April 12, 2020, for RCTs of either placebo-controlled or active-controlled design containing information on the incidence of emergence delirium in pediatric patients undergoing sevoflurane anesthesia. Main results: Seventy studies comprising 6904 participants were included for the analysis of 30 pharmacological interventions. Based on surface under the cumulative ranking curve (SUCRA) analysis, midazolam was ranked the lowest in therapeutic effect (SUCRA: 20%), while antiemetics as a monotherapy had no effect on delirium prophylaxis. However, there was a trend that most combination therapies with midazolam or antiemetics were superior to monotherapies for delirium prophylaxis. Subgroup analyses based on age (i.e., ≤7 years) and a validated scoring system (i.e., the Pediatric Anesthesia Emergence Delirium scale) for delirium also suggested a better efficacy of combination therapies than monotherapies. Overall, combination therapies with midazolam or antiemetics did not have a negative impact on the incidence of postoperative nausea and vomiting, length of stay in the postanesthesia care unit, or time to extubation. The dexmedetomidine-midazolam-antiemetic combination was the most effective strategy for the prevention of emergence delirium. Conclusions: This network meta-analysis suggested that the incorporation of midazolam or antiemetics as adjuncts for combination therapies may have synergistic effects against pediatric postoperative emergence delirium. Future large-scale placebo-controlled RCTs are warranted to validate our findings.

KW - Combination therapy

KW - Emergence delirium

KW - Network meta-analysis

KW - Pediatric anesthesia

KW - Sevoflurane

UR - http://www.scopus.com/inward/record.url?scp=85113927492&partnerID=8YFLogxK

U2 - 10.1016/j.jclinane.2021.110488

DO - 10.1016/j.jclinane.2021.110488

M3 - Review article

AN - SCOPUS:85113927492

SN - 0952-8180

VL - 75

JO - Journal of clinical anesthesia

JF - Journal of clinical anesthesia

M1 - 110488

ER -

Association of pharmacological prophylaxis with the risk of pediatric emergence delirium after sevoflurane anesthesia: An updated network meta-analysis

Abstract

Keywords

Access to Document

Other files and links

Fingerprint

Cite this