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Efficacy and safety of caudal dexmedetomidine in pediatric infra-umbilical surgery: a meta-analysis and trial-sequential analysis of randomized controlled trials
  1. Ushma Jitendra Shah1,2,
  2. Derek Nguyen3,
  3. Niveditha Karuppiaah2,4,
  4. Janet Martin1,4 and
  5. Herman Sehmbi1
  1. 1Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
  2. 2Anesthesia & Perioperative Medicine, London Health Sciences Centre Children's Hospital, London, Ontario, Canada
  3. 3Bachelor of Medical Sciences, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
  4. 4Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
  1. Correspondence to Dr Herman Sehmbi, Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada; Herman.Sehmbi{at}


Background Dexmedetomidine is used as a local-anesthetics adjuvant in caudal block to prolong analgesia in pediatric infra-umbilical surgery.

Objective We evaluated the analgesic efficacy and safety of the addition of caudal dexmedetomidine to local anesthetics (vs local anesthetics alone) in pediatric infra-umbilical surgery.

Evidence review We searched 10 databases for randomized controlled trials (RCTs) of pediatric patients undergoing infra-umbilical surgery, comparing caudal block with and without dexmedetomidine as local anesthetic adjuvant. We performed a frequentist random-effects meta-analysis (R statistical package). We analyzed continuous outcomes as a ratio of means (ROM) and dichotomous data as relative risk (RR), along with 95% CI. We included 19 RCTs (n=1190 pediatric patients) in the meta-analysis. The primary outcome was duration of analgesia (defined as ‘the time from caudal injection to the time at which the study-specific pain score was greater than a cut-off threshold’).

Findings Data from 19 included RCTs (n=1190) suggested that compared with control (mean duration 346 min), the addition of caudal dexmedetomidine significantly prolonged the duration of analgesia (ratio of means 2.14, 95% CI 1.83 to 2.49, p<0.001; ‘moderate’ evidence). Trial-sequential analysis showed adequate ‘information size’ for the primary outcome. Caudal dexmedetomidine also reduced the number of analgesic administrations (‘low’ evidence), total acetaminophen dose (‘moderate’ evidence) and the risk of emergence delirium (‘moderate’ evidence). There were no significant differences in adverse effects such as hypotension, bradycardia, post-operative nausea and vomiting, urinary retention and respiratory depression.

Conclusions Our results suggest that the addition of dexmedetomidine to local anesthetic in caudal block significantly improves the duration of analgesia and reduces the analgesic requirements, while maintaining a similar risk-profile compared with local anesthetic alone. Further data on neurological safety are needed.

  • pediatrics
  • anesthesia
  • local
  • pain
  • postoperative
  • acute pain
  • regional anesthesia

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  • Contributors UJS, JM and HS conceptualized the study and wrote the protocol; UJS and NK performed the initial study screening; DK and NK performed the full-text review and data extraction; UJS, NK and HS performed the risk of bias assessment; HS and JM did the statistical analysis. All authors contributed to the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Extracted data are available on reasonable request. This can also be provided as dataset files and R codes (or R Markdown files) for scrutiny or re-analysis for future studies. Detailed methods and R codes are already provided in the supplementary file.