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Prophylaxis for paediatric emergence delirium in desflurane-based anaesthesia: a network meta-analysis

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Abstract

Purpose

The prevalence of postoperative emergence delirium in paediatric patients (pedED) following desflurane anaesthesia is considerably high at 50–80%. Although several pharmacological prophylactic strategies have been introduced to reduce the risk of pedED, conclusive evidence about the superiority of these individual regimens is lacking. The aim of the current study was to assess the potential prophylactic effect and safety of individual pharmacotherapies in the prevention of pedED following desflurane anaesthesia.

Methods

This frequentist model network meta-analysis (NMA) of randomized controlled trials (RCTs) included peer-reviewed RCTs of either placebo-controlled or active-controlled design in paediatric patients under desflurane anaesthesia.

Results

Seven studies comprising 573 participants were included. Overall, the ketamine + propofol administration [odds ratio (OR) = 0.05, 95% confidence intervals (95%CIs) 0.01–0.33], dexmedetomidine alone (OR = 0.13, 95%CIs 0.05–0.31), and propofol administration (OR = 0.30, 95%CIs 0.10–0.91) were associated with a significantly lower incidence of pedED than the placebo/control groups. In addition, only gabapentin and dexmedetomidine were associated with a significantly higher improvement in the severity of emergence delirium than the placebo/control groups. Finally, the ketamine + propofol administration was associated with the lowest incidence of pedED, whereas gabapentin was associated with the lowest severity of pedED among all of the pharmacologic interventions studied.

Conclusions

The current NMA showed that ketamine + propofol administration was associated with the lowest incidence of pedED among all of the pharmacologic interventions studied. Future large-scale trials to more fully elucidate the comparative benefits of different combination regimens are warranted.

Trial registration

PROSPERO CRD42021285200.

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Availability of data and materials

All the data of the current study were available upon reasonable request to the corresponding authors.

Abbreviations

CI:

Confidence interval

Dex:

Dexmedetomidine

ES:

Effect size

FeMi:

Fentanyl + midazolam

Gab:

Gabapentin

GABA:

Gamma-aminobutyric acid

KeP:

Ketamine + propofol

Mid:

Midazolam

NMA:

Network meta-analysis

OR:

Odds ratio

pedED:

Postoperative emergence delirium in pediatric population

Pla:

Placebo/control

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

Pro:

Propofol

RCT:

Randomized controlled trial

SMD:

Standardized mean difference

SUCRA:

Surface under the cumulative ranking curve

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Funding

The current work did not receive any financial support. 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. The other authors did not receive any assistance, financial support or sponsorship. This paper presents independent research. The views expressed in this publication are those of the authors and not necessarily those of the acknowledged institutions.

Author information

Author notes

  1. Hung-Chang Kuo, Kuo-Chuan Hung, Hung-Yu Wang and Bing-Syuan Zeng contributed equally as first authors.

  2. Chih-Wei Hsu, Mein-Woei Suen and **-Tao Tseng contributed equally as corresponding authors.

Authors and Affiliations

  1. Department of Neurology, E-Da Hospital/School of Medicine, I-Shou University, Kaohsiung, Taiwan

    Hung-Chang Kuo & Shih-Pin Hsu

  2. Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan

    Kuo-Chuan Hung

  3. Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan

    Hung-Yu Wang

  4. Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan

    Bing-Syuan Zeng

  5. Department of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan

    Tien-Yu Chen

  6. Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan

    Tien-Yu Chen

  7. Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan

    Dian-Jeng Li

  8. Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

    Pao-Yen Lin

  9. Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

    Pao-Yen Lin

  10. Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

    Brendon Stubbs

  11. Mind-Body Interface Research Center (MBI-Lab), China Medical University Hospital, Taichung, Taiwan

    Kuan-Pin Su

  12. College of Medicine, China Medical University, Taichung, Taiwan

    Kuan-Pin Su

  13. An-Nan Hospital, China Medical University, Tainan, Taiwan

    Kuan-Pin Su

  14. Department of Anesthesiology, Shin Huey Shin Hospital, Kaohsiung, Taiwan

    Min-Hsien Chiang

  15. Innovation in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia

    Andre F. Carvalho

  16. Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK

    Brendon Stubbs

  17. Positive Ageing Research Institute (PARI), Faculty of Health, Social Care Medicine and Education, Anglia Ruskin University, Chelmsford, UK

    Brendon Stubbs

  18. Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan

    Yu-Kang Tu

  19. Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan

    Yu-Kang Tu

  20. Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan

    Yi-Cheng Wu

  21. Institute for Mental Health Policy Research, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Canada

    Michael Roerecke

  22. Center for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK

    Lee Smith

  23. Prospect Clinic for Otorhinolaryngology and Neurology, No. 252, Nanzixin Road, Nanzi District, Kaohsiung City, 81166, Taiwan

    Yen-Wen Chen & **-Tao Tseng

  24. Department of Psychology, College of Medical and Health Science, Asia University, No. 500, Liufeng Road, Wufeng District, Taichung City, 413, Taiwan

    Pin-Yang Yeh, Mein-Woei Suen & **-Tao Tseng

  25. Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833, Taiwan

    Chih-Wei Hsu

  26. Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan

    Bing-Syuan Zeng & **-Tao Tseng

  27. Institute of Precision Medicine, National Sun Yat-Sen University, Kaohsiung City, Taiwan

    **-Tao Tseng

  28. Gender Equality Education and Research Center, Asia University, Taichung, Taiwan

    Mein-Woei Suen

  29. Department of Medical Research, Asia University Hospital, Asia University, Taichung, Taiwan

    Mein-Woei Suen

  30. Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan

    Mein-Woei Suen

  31. School of Medicine, National Defense Medical Center, Taipei, Taiwan

    Tien-Yu Chen

  32. Dalla Lana School of Public Health (DLSPH), University of Toronto, Toronto, Canada

    Michael Roerecke

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  1. Hung-Chang Kuo
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Contributions

HCK contributed as the first author and took the whole responsibility of manuscript drafting and data analysis. KCH contributed as the first author and study design, concept formation, data analysis, and drafting manuscript. HYW contributed as the first author and concept formation, manuscript revision, data validataion, data extraction, visualization, and manuscript drafting. BSZ contributed as the first author and took the whole responsibility of data extraction, data analysis, data approval, and manuscript drafting. TYC contributed in study design, concept formation, data extraction, and data analysis. DJL contributed in concept formation, method design, literature screen and selection. PYL contributed in data curation, data analysis, statitical process, and manuscript revision. KPS contributed in study design, data analysis, validation of data, and visualization. MHC contributed in concept formation, literature screen/selection, supervision of data extraction, and validation. AFC contributed in data curation and validation, visualization, and manuscript revision. BS contributed in concept formation, literature screen, and data extraction. YKT contributed in data analysis, data validation, data analysis, and supervision. YCW contributed in data analysis, visualization, manuscript revision, and data validatation. MR contributed in concept formation, study design, literature screen and selection. LS contributed in study design, manuscript revision, and data validation. SPH contributed in manuscript revision, supervision, and data extraction. YWC contributed in data analysis, data extraction, analysis process, and manuscript revision. PYY contributed in concept formation, study design, and manuscript revision. CWH contributed equally as the corresponding author and manuscript revision, data extraction, data analysis, and manuscript submission. PTT contributed equally as the corresponding author and manuscript revision, data analysis, data collection, and manuscript submission. MWS contributed equally as the corresponding author and manuscript revision, data analysis, data collection, and manuscript submission.

Corresponding authors

Correspondence to Chih-Wei Hsu, Mein-Woei Suen or **-Tao Tseng.

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The current study complies for the Institutional Review Board of the Tri-Service General Hospital (TSGHIRB: B-105-12). The current study did not direct involve individual participant so that we did not have the chance to approach individual participant or explore individual participant’s information. Therefore, it would be impossible to obtain Consent to Participate in the current study.

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The current study did not direct involve individual participant so that we did not have the chance to approach individual participant or explore individual participant’s information. Therefore, it would be impossible to obtain Consent to Publish in the current study.

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Kuo, HC., Hung, KC., Wang, HY. et al. Prophylaxis for paediatric emergence delirium in desflurane-based anaesthesia: a network meta-analysis. J Anesth 38, 155–166 (2024). https://doi.org/10.1007/s00540-023-03219-y

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