Does a prophylactic dose of propofol reduce emergence agitation in children receiving anesthesia? A systematic review and meta-analysis.
BACKGROUND
Emergence agitation (EA) is common after sevoflurane anesthesia in children, and can lead to distressing inconsolability, agitation, crying, and injury. Use of a single dose of the short-acting sedative-hypnotic agent propofol at the end of a procedure has shown promise for preventing EA, but evidence evaluating the efficacy and safety of this approach has not been formally summarized.


OBJECTIVE
The objective of this review was to assess the effects of a prophylactic dose of propofol vs placebo on the incidence and severity of EA in children age 0-13 years receiving general inhalational anesthesia.


METHODS
We searched PubMed (1946-2013) via Medline, CENTRAL (1898-2013), and Web of Science (1900-2013) without limits or language restrictions; we also searched ClinicalTrials.gov and reference lists. We reviewed abstracts from the 2012 and 2013 Society for Pediatric Anesthesia meetings and pediatric anesthesia-related abstracts from the 2012 and 2013 International Anesthesia Research Society meetings.


METHODS
We assessed randomized, double-blind trials evaluating the efficacy of a prophylactic dose of propofol (1 mg·kg(-1) ) vs placebo given at the end of inhalational anesthesia to prevent EA in pediatric patients. Studies were required to follow patients through recovery and report at least one prespecified outcome.


METHODS
Two authors independently assessed trial quality and extracted data from included studies. We contacted study authors regarding any missing data. We used the random effects models to calculate pooled relative risks (RR) and weighted mean differences (WMD). We collected Pediatric Anesthesia Emergence Delirium (PAED) scale scores from included studies. PAED scale scores can range from 0 to 20.


RESULTS
Of 276 studies screened, nine trials involving 997 children met all inclusion criteria. All were considered low risk of bias. For one non-English trial, we obtained a full-text translation and for one non-English trial, we used the English-language abstract, tables, and figures. Based on available evidence, prophylactic propofol was associated with both decreased incidence of EA (29% vs 58%, RR 0.50, 95% confidence intervals [CI] 0.41, 0.61, I(2) = 37%, seven studies), and reduced severity of EA as assessed by mean PAED scale score (WMD -2.08 points, 95% CI -3.20, -0.96, I(2) = 0%, three studies), when compared to placebo. In addition, though prophylactic propofol did lengthen the time to awakening (WMD 4.07 min, 95% CI 2.22, 5.91, I(2) = 82%, six studies), it did not increase recovery time (WMD 2.91 min, 95% CI -0.59, 6.41, I(2) = 82%, six studies) when compared to placebo. No significant adverse events were reported in either arm.


CONCLUSIONS
Based on high quality evidence, prophylactic propofol appears to be effective for reducing the incidence and severity of EA in children emerging from general anesthesia.
Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.|Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Sophia L
SL
van Hoff
Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Elizabeth S
ES
O'Neill
Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Lianna C
LC
Cohen
Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Brian A
BA
Collins
D000293:Adolescent; D000762:Anesthesia Recovery Period; D018685:Anesthetics, Inhalation / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D007223:Infant; D008738:Methyl Ethers / Q000009:adverse effects*; D015742:Propofol / Q000627:therapeutic use*; D011595:Psychomotor Agitation / Q000209:etiology / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D000077149:Sevoflurane; D015599:Trauma Severity Indices
D018685:Anesthetics, Inhalation; D006993:Hypnotics and Sedatives; D008738:Methyl Ethers; D000077149:Sevoflurane; D015742:Propofol
anesthesia; child; delirium; pediatrics; propofol; psychomotor agitation