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Adjunct with inhalational anaesthesia for procedures
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| bet | 154/654 | | Sana | 03.01.2022 | | Hajmi | 1,5 Mb. | | #14803 |
Adjunct with inhalational anaesthesia for procedures: A systematic review [12] of RCTs in paediatric patients undergoing inhalational anaesthesia using sevoflurane included 14 RCTs involving painful procedures in children and infants of whom 777 received dexmedetomidine and 693 received placebo. No trial enrolled newborns. Bolus dexmedetomidine dose ranged from 0.3 to 2 microgram/kg and maintenance dose 0.1 to 0.7 microgram/kg/hour. Intraoperative dexmedetomidine was associated with reduced postoperative opioid use in the post-anaesthesia care unit [RR 0.31 (0.17, 0.59), I2= 76%, p<0.0001], decreased post-operative pain intensity [SMD -1.18 (-1.88, -0.48), I2 = 91%, p<0.0001] but had no effect upon postoperative nausea and vomiting incidence [RR = 0.67 (0.41, 1.08), I2 = 0%, p = 0.48]. Subgroup analyses found administration during adeno-tonsillectomy and using a bolus <0.5 microgram/kg irrespective of continuous administration was associated with no effect. This supports the findings of a previous systematic review [13] of use of intraoperative dexmedetomidine compared to opioids or placebo for acute postoperative pain in children which included 11 RCTs with 874 children. A lower risk for postoperative pain and need for postoperative opioids following intraoperative dexmedetomidine compared with placebo or opioids in children undergoing surgery was reported. Five trials including 240 patients reported bradycardia or hypotension, with one episode of bradycardia treated with atropine and two episodes of hypotension treated with saline bolus. Newborns were not included in the trials. [LOE I in infants and children]
A network meta-analysis of RCTs [14] assessing the effects of different auxiliary drugs in paediatric sevoflurane anaesthesia found dexmedetomidine reduced likelihood of emergent agitation, reduced post-operative nausea and vomiting, decreased sedative use and reduced paediatric anaesthesia emergence delirium compared to placebo, but was associated with a longer extubation time compared to those who were given placebo. Compared to other agents, fentanyl was more effective than dexmedetomidine in reducing risk of emergence agitation and paediatric anaesthesia emergence delirium, but patients were more likely to experience postoperative nausea and vomiting and require additional analgaesia compared to those in the dexmedetomidine group. The network meta-analysis concluded dexmedetomidine should be considered as the most appropriate prophylactic treatment that can be introduced into sevoflurane anaesthesia. Newborns were not included in the trials. [LOE I in infants and children].
Three case series have reported use of dexmedetomidine as an adjunct to anaesthetic in infants undergoing surgical procedures. [15-17] Ozcengiz et al [16] reported 16 newborns aged 2-28 days who underwent general anaesthesia using dexmedetomidine and sevoflurane for abdominal surgical procedures. Excluded from the report were 4 infants who experienced bradycardia treated with atropine which led to a change in the induction protocol. Anaesthesia was induced with 1 microgram/kg ketamine intravenously, then dexmedetomidine 1 μg/kg infused over 10 minutes. Maintenance infusion was started as 0.5-0.8 μg/kg/hour until the end of surgery. No significant differences were observed in haemodynamic parameters from baseline values. No patient had hypotension, bradycardia, hypertension, hypoxia or respiratory depression. Patients had mild to moderate hypothermia during the postoperative period. Lam et al [15] reported a case series of 50 neonates and infants with heart disease. Use of a dexmedetomidine infusion during and/or after heart surgery was safe from a haemodynamic standpoint. Sellas et al [17] reported a retrospective case control study comparing postoperative infusion of dexmedetomidine with opioid infusion (n=39 each group), of which 31 out of 35 newborns were mechanically ventilated. Average dose of dexmedetomidine was 0.36 microgram/kg/hour. Dexmedetomidine reduced the cumulative dose of opioids but not the number of doses, and was associated with an increase in bradycardia episodes (12.8 versus 5.1%), but not hypotension or respiratory depression. Average dose associated with bradycardia was 0.3 microgram/kg/hour. [LOE IV newborns]
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