Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2021.07.026
Brazilian Journal of Anesthesiology
Systematic Review

Oral preanesthetic medication in children – comparison between midazolam alone and in combination with ketamine: a systematic review and meta-analysis

Medicação pré-anestésica oral em crianças – comparação entre midazolam isolado e em combinação com cetamina: revisão sistemática e meta-análise

Getúlio Rodrigues de Oliveira Filho; Carlos Maestri Castilhos; Jean Philippe Kriegl; Giulia Nonticuri Bianchi

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Abstract

Background
Up to 60% of pediatric surgical patients develop high levels of preoperative anxiety. This study compared the effects of oral combinations of midazolam and ketamine with oral midazolam alone for pediatric preanesthetic medication.

Methods
The study protocol was registered in PROSPERO as CRD42020172920. A systematic literature search was conducted using Medline, Cochrane, EMBASE, CENTRAL, and Web of Science for randomized controlled trials comparing oral combinations of midazolam and ketamine with midazolam alone as preanesthetic medication in elective surgical pediatric patients. Meta-analyses included the following outcomes: anxiety and sedation levels, child’s behavior during separation from parents, face mask acceptance, and venipuncture. The quality of evidence was assessed using GRADE criteria.

Results
Twenty studies were included. The following effects (RR (95% CI)) were observed for combinations of ketamine and midazolam relative midazolam alone: anxiolysis (1.2 (0.94–1.52);p =  0.15; I2 = 80%; GRADE = very low); satisfactory sedation (1.2 ( 1.10–1.31); p < 0.001; I2 = 71%; GRADE = very low); behavior during parental separation (1.2 (1.06–1.36); p = 0.003; I2 = 88%; GRADE = very low); facial mask acceptance (1.13 (1.04–1.24); p = 0.007; I2 = 49%; GRADE = very low); behavior during venipuncture (1.32 (1.11–1.57); p = 0.002; I2 = 66%; GRADE = very low).

Conclusions
While similar probabilities of obtaining anxiolysis were found, adequate sedation, calm behavior during child’s separation from parents, low levels of fear during face mask adaptation, and cooperative behavior during peripheral venous cannulation were more likely with midazolam-ketamine combinations.

Keywords

Medication, preanesthetic;  Child;  Pediatrics, surgery;  Cyclohexanes, ketamine;  Benzodiazepines, midazolam

Resumo

Introdução

Até 60% dos pacientes cirúrgicos pediátricos desenvolvem altos níveis de ansiedade pré-operatória. Este estudo comparou os efeitos de combinações orais de midazolam e cetamina com midazolam oral sozinho para medicação pré-anestésica pediátrica.

Métodos

O protocolo do estudo foi registrado no PROSPERO como CRD42020172920. Uma busca sistemática da literatura foi realizada usando Medline, Cochrane, EMBASE, CENTRAL e Web of Science para ensaios clínicos randomizados comparando combinações orais de midazolam e cetamina com midazolam sozinho como medicação pré-anestésica em pacientes pediátricos cirúrgicos eletivos. As metanálises incluíram os seguintes resultados: níveis de ansiedade e sedação, comportamento da criança durante a separação dos pais, aceitação da máscara facial e punção venosa. A qualidade da evidência foi avaliada usando critérios GRADE.

Resultados

Vinte estudos foram incluídos. Os seguintes efeitos (RR (95% CI)) foram observados para combinações de cetamina e midazolam em relação ao midazolam sozinho: ansiólise (1,2 (0,94–1,52); p = 0,15; I2 = 80%; GRADE = muito baixo); sedação satisfatória (1,2 (1,10–1,31); p < 0,001; I2 = 71%; GRADE = muito baixo); comportamento durante a separação dos pais (1,2 (1,06–1,36); p = 0,003; I2 = 88%; GRADE = muito baixo); aceitação da máscara facial (1,13 (1,04–1,24); p = 0,007; I2 = 49%; GRADE = muito baixo); comportamento durante a punção venosa (1,32 (1,11–1,57); p = 0,002; I2 = 66%; GRADE = muito baixo).

Conclusões

Embora tenham sido encontradas probabilidades semelhantes de obter ansiólise, sedação adequada, comportamento calmo durante a separação da criança dos pais, baixos níveis de medo durante a adaptação da máscara facial e comportamento cooperativo durante a canulação venosa periférica foram mais prováveis com combinações de midazolam-cetamina.

Palavras-chave

Medicação pré-anestésica; Criança; Cirurgia pediátrica; Ciclohexanos, cetamina; Benzodiazepínicos, midazolam

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