Comparative effect of nonpharmacological interventions on emergence delirium prevention in children following sevoflurane general anesthesia: a systematic review and network meta-analysis of randomized controlled trials

Background: Children receiving general anesthesia while undergoing surgery have a significantly high incidence of emergence delirium (ED). Nonpharmacological interventions yield beneficial effects on preventing pediatric ED. However, the relative effects of nonpharmacological interventions on pediatric ED prevention based on various perioperative phases remain unknown. Objective: To compare the effects of nonpharmacological interventions on pediatric ED prevention at different surgical phases. Design: A systematic review and network meta-analysis. Data sources: A comprehensive search of five electronic databases (PubMed, CINAHL via EBSCOhost, Embase via Elsevier, Cochrane Trials, and ProQuest Dissertations and theses) for identifying randomized control trials published from inception to October 15, 2023. Methods: Two reviewers independently screened, assessed, and extracted data from the eligible studies. A random-effects network meta-analysis was used to determine the comparative effect of nonpharmacological interventions on preventing pediatric ED. Results: A total of 19 studies involving 2522 children were included in this network meta-analysis. Thirteen studies reported on the prevention of pediatric ED in the preoperative phase, and six studies reported on the prevention of pediatric ED in the intraoperative phases. Multimedia devices (OR 0.39, 95 % CIs 0.20–0.74), a multicomponent program (OR 0.20, 95 % CI 0.14–0.28) significantly reduced the incidence of pediatric ED during the preoperative phase compared with usual care. During the intraoperative phase, listening to regular heartbeat sounds significantly reduced the risk of pediatric ED compared with usual care (OR 0.06, 95 % CI 0.02–0.22), placebo (OR 0.11, 95 % CI 0.03–0.36), acupuncture (OR 0.17, 95 % CI 0.03–0.88), acupuncture with electrical stimulus (OR 0.16, 95 % CI 0.04–0.68), and acupuncture with midazolam (OR 0.04, 95 % CI 0.00–0.41). Conclusions: Our study results suggest that the multicomponent program and listening to heartbeat sounds are relatively effective nonpharmacological interventions for preventing pediatric ED during the perioperative phase. This study compared the effectiveness and ranking of various interventions, and the findings can serve as a guide to assist health professionals in choosing the optimal strategy for preventing ED. Registration: The study protocol was registered at PROSPERO (CRD42023459541). Tweetable abstract: Nonpharmacological interventions can reduce the high incidence of pediatric emergence delirium after surgery. Our systematic review highlights the efficacy of multicomponent programs and listening to heartbeat sounds intraoperatively in reducing ED risk. The findings aid health professionals in selecting optimal strategies for pediatric perioperative care.