Delayed emergence process does not result in a lower incidence of emergence agitation after sevoflurane anesthesia in children

BACKGROUND: Emergence agitation (EA) is more frequent after sevoflurane anesthesia than other inhalational agents but the etiology remains unclear. We investigated whether the EA after sevoflurane anesthesia is related to rapid emergence. METHODS: Eighty-five patients, aged 1-7 years, undergoing elective urology surgery were studied. After induction, anesthesia was maintained with 2.0-2.5% sevoflurane and 50% N(2)O. BIS was monitored continuously throughout surgery and emergence. At the end of surgery, the children were randomly assigned to one of two groups: group I, immediate cessation of sevoflurane; or group G, gradual decrease of sevoflurane with the rate of 0.1%.min(-1). Emergence agitation score was recorded during recovery. RESULTS: Times from immediate cessation or start of decrease of sevoflurane to BIS 70, 80, 90 and extubation were significantly longer in group G. The incidence of severe agitation (score > or =3) was not significantly different between group I and group G: which were 35.7% and 32.6%, respectively. CONCLUSION: Prolonged recovery did not reduce the incidence of EA following sevoflurane anesthesia in children.     

Preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia

BACKGROUND: The frequency of emergence agitation in children is increased following sevoflurane anesthesia. However, controversies still exist concerning the exact etiology of this postanesthetic problem. Although this phenomenon is present with adequate pain relief or even following pain-free procedures, pain is still regarded as a major contributing factor. METHODS: In a prospective, randomized, double-blind study, we enrolled 48 premedicated and calm 2-6-year-old children undergoing inguinal hernia repair. We assigned children to one of two groups: children assigned to the caudal group (n = 24) received a caudal block to supplement sevoflurane, while children assigned to the fentanyl group (n = 24) received a bolus injection of 1 microg kg(-1) intravenous fentanyl before skin incision to supplement sevoflurane. In the post anesthesia care unit, all children were received by their parent, and the incidence of emergence agitation and pain scores, as well as hemodynamic changes, were compared in both groups. RESULTS: Forty-four children completed the study. In the fentanyl group, 59% of the children were agitated following emergence from anesthesia as compared to 4.5% in the caudal group (P < 0.001). Also, pain scores, mean values of heart rate and blood pressure as well as morphine requirement were significantly higher in the post anesthesia care unit in the fentanyl group compared to the caudal group. CONCLUSION: Our results show that in children undergoing inguinal hernia repair, pain control with a preoperative caudal block as compared to intraoperative intravenous fentanyl significantly reduces the incidence of emergence agitation and pain scores following sevoflurane anesthesia.     

Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile

BACKGROUND: Emergence agitation (EA) is a common postoperative problem in young children who have received sevoflurane and isoflurane for general anesthesia. This randomized, double-blinded study evaluated the efficacy of intraoperative clonidine in reducing EA, and describes its recovery profile. METHODS: With Institutional Review Board approval and informed consent, children undergoing brief, minimally painful procedures were studied. All children received preemptive analgesia with acetaminophen and ketorolac, sevoflurane for induction, and isoflurane for maintenance of anesthesia. Children received either 2 microg.kg(-1) clonidine or placebo intravenously (i.v.) following induction of anesthesia. Children were observed postoperatively for behavior and side effects, and their parents were telephoned the next day to determine postdischarge recovery characteristics. RESULTS: One hundred and twenty children were included in this study: 59 of whom received clonidine, and 61 placebo; 41% of those in the placebo group exhibited moderate-severe EA compared with only 22% of those in the clonidine group (P < 0.03). Compared with those who received placebo, children who received clonidine awakened more slowly (22 min vs 14 min), had a longer postanesthesia care unit stay (57 min vs 46 min), and experienced sleepiness more frequently after discharge (75% vs 39%; all comparisons significant at P < 0.03). There were no adverse cardiorespiratory events in either group. CONCLUSIONS: Findings demonstrate that i.v. clonidine administered after induction of anesthesia significantly reduces the incidence of EA in young children, but is associated with sleepiness postoperatively.     

右美托咪定静脉泵注和鼻内给药两种方式对小儿口腔日间手术术后躁动的影响

目的比较右美托咪定静脉泵注和鼻内给药两种方法对七氟烷吸入麻醉下小儿口腔日间手术术后躁动的影响。方法随机纳入135例拟行口腔日间手术的患儿,年龄1~6岁,分为3组,每组45例,分别予麻醉诱导后右美托咪定1μg/kg静脉泵注(VD组)、麻醉诱导前15 min右美托咪定1μg/kg鼻内给药(ND组)或等量生理盐水对照(C组)。所有患儿采用七氟烷全凭吸入麻醉。术后每5 min进行一次躁动评分(PEDA)及疼痛评分(FLACC);记录麻醉诱导前(T0)、麻醉诱导后(T1)、手术开始时(T2)、手术结束时(T3)及苏醒时(T4)的HR、BP;记录苏醒时间、PACU停留时间及恶心呕吐、呼吸抑制、心动过缓等不良反应发生情况。结果 VD组和ND组术后躁动发生率明显低于C组(P0.01);T2和T3时VD组心率明显低于ND组和C组(P0.01),T3时ND组心率低于C组(P0.05);VD组和ND组苏醒时间长于C组(P0.01);3组患儿PACU停留时间没有差异;3组患儿最高疼痛评分没有差异。VD组有4例患儿出现心动过缓需使用阿托品治疗。3组患儿均未发生其他严重不良反应。结论右美托咪定静脉泵注和鼻内给药都能明显降低七氟烷麻醉后躁动的发生,右美托咪定鼻内给药对心率影响更小。     

Emergence agitation after cataract surgery in children: a comparison of midazolam,propofol and ketamine

Objectives: The aim of this study was to determine whether the concurrent use of either of a subhypnotic dose of midazolam, propofol or ketamine with fentanyl just before discontinuing the sevoflurane anesthesia would effectively sedate the children as they recovered and significantly decrease the incidence and severity of emergence agitation and would not delay patient awakening and discharge. Background: Postoperative emergence agitation may occur in children after general anesthesia with volatile anesthetics. Children who undergo cataract surgery after sevoflurane induction and sevoflurane–remifentanil maintenance may experience this type of agitation. Methods/Materials: In 120 un‐premedicated children aged 1–7 years, mask induction with sevoflurane was performed and they were then randomly assigned to one of the three antiagitation postoperative groups (n = 40). We studied the postoperative antiagitation effects of subhypnotic doses of midazolam combined with fentanyl, propofol with fentanyl or ketamine with fentanyl administered just before discontinuing the sevoflurane anesthesia. A score for the level of agitation can be assigned based on the recovery mental state (RMS) scale and the recently published pediatric anesthesia emergence delirium scale (PAED). Postoperative factors assessed included emergence behaviors, the time to eye opening, the time to discharge from the postanesthesia care unit (PACU) to the ward. Results: There were significantly more agitated children in the ketamine‐group when compared to the midazolam‐group or to the propofol‐group at all time P < 0.05), especially at 10 and 15 min. The PAED scale showed a significant advantage for midazolam–fentanyl [5 (2–15)] and propofol–fentanyl [6 (3–15)] versus ketamine–fentanyl [10 (3–20)] (P < 0.05). The time to discharge from the PACU to the ward was not significantly different among the groups. Conclusions: Intravenous administration of a subhypnotic dose of midazolam or propofol in addition to a low dose of fentanyl just before discontinuing the sevoflurane anesthesia was both effective on decreasing the incidence and severity of emergence agitation in children undergoing cataract extraction without significant delaying recovery time and discharge. The effect of midazolam was clearer than that seen with propofol.     

右美托咪定对老年患者脊柱手术苏醒期躁动的影响

目的观察右美托咪定对老年患者脊柱手术后苏醒期躁动(EA)的影响。方法老年患者(年龄≥60岁)60例,随机分为右美托咪定组(D组)和对照组(C组),每组30例。麻醉诱导后D组患者持续泵注右美托咪定每小时0.4μg/kg,C组持续泵注等容量的生理盐水,手术结束时停药。入麻醉恢复室(PACU)后进行Richmond躁动镇静(RASS)评分,记录EA发生率。记录患者清醒时间、气管导管拔除时间及PACU停留时间。术后24小时记录患者对苏醒期治疗的满意度。结果 D组患者EA发生率为16.67%,C组为46.67%,两组比较差异有统计学意义(P0.05),D组患者PACU停留时间为(42.17士17.40)分钟,C组为(52.50±22.12)分钟,两组比较差异有统计学意义(P0.05)。D组患者清醒时间为(16.67±7.58)分钟,拔管时间为(21.67±7.58)分钟,C组分别为(14.40±8.47)分钟和(19.10±8.86)分钟,两组比较差异无统计学意义(P0.05)。结论右美托咪定可以有效地降低老年患者脊柱手术后EA发生率,提高患者苏醒质量。     

Dexmedetomidine decreases emergence agitation in pediatric patients after sevoflurane anesthesia without surgery

BACKGROUND: The purpose of the present study was to determine whether prophylactic use of 1 microg x kg(-1) dexmedetomidine affected the incidence of emergence agitation (EA) after sevoflurane based anesthesia without surgery in children. METHODS: In a double-blinded trial, 42 children (ASA I-II,18 months to 10 years) undergoing magnetic resonance imaging (MRI) examination were randomly assigned to receive dexmedetomidine 1 microg x kg(-1) iv or placebo after induction of anesthesia. Heart rate (HR), mean arterial pressure (MAP), hemoglobin oxygen saturation (SpO2) were monitored. Anesthesia was induced in all patients, irrespective of group, with 8% sevoflurane in 50-50% O2/N2O and maintained with 1.5% sevoflurane in 50/50% O2/N2O. Agitation parameters were assessed with a 5-point scale and measured every 5 min. Delirium was defined as agitation score of > or =4 for > or =5 min. Anesthesia and procedure times and per- and postoperative side effects were recorded. RESULTS: The HR, MAP, and SpO2, spontaneous arm or leg motion times and purposeful movement times showed no significant differences between the two groups. The time of removing the LMA, and the time of eye opening with verbal stimuli was shorter in group P than the group D (P = 0.007 and P = 0.01). The time of discharge to recovery room and the time of discharge from hospital were similar in the two groups. The mean agitation scores in the dexmedetomidine group were significantly lower than the placebo group except at 30 min (P < 0.0001, P = 0.001, P = 0.002, P = 0.013 and P = 0.001). The incidence of emergence agitation was 47.6% in group P, and 4.8% in group D (P = 0.002). CONCLUSION: We concluded that a 1 microg x kg(-1) dose of i.v. dexmedetomidine reduces EA after sevoflurane anesthesia in children undergoing MRI.     

The effect of dexmedetomidine during myringotomy and pressure-equalizing tube placement in children

Background: Bilateral myringotomy (BMT) is a commonly performed otolaryngologic procedure in children. Objectives: To examine the effects of intranasal dexmedetomidine, an α₂‐adrenoceptor agonist, on time‐averaged pain scores, pain control, need for rescue analgesia, and agitation scores in children undergoing BMT. Methods: We designed a trial to enroll 160 children randomized to one of four groups: two study groups, dexmedetomidine (1 or 2 μg·kg^?1), or two control groups representing our institutional standards of practice (intranasal fentanyl‐2 μg·kg^?1 or acetaminophen as needed postoperatively). Results: After 101 children were enrolled, patient caregivers observed that some enrollees were excessively sedated and required prolonged postanesthesia care unit (PACU) stay. This observation led to an unplanned interim analysis and early trial termination. After data were collected, severe nonnormality of pain and agitation scores necessitated a switch of the outcome to assess repeated measurements of the proportion of patients with pain, severe pain, and agitation. Demographics, time to emergence, and agitation were similar among all groups. The risk of requiring acetaminophen rescue (P < 0.0001) and proportion of patients having pain (P = 0.016) was significantly higher in one control group (rescue analgesia only) compared with fentanyl or dexmedetomidine groups. Importantly, length of stay in the PACU was significantly longer in dexmedetomidine‐2 μg·kg^?1‐treated compared with dexmedetomidine‐1 μg·kg^?1‐treated, fentanyl‐treated, or the control group, P = 0.0037. Conclusions: In this trial, we were unable to answer the original question as to the role of dexmedetomidine on time‐averaged pain and agitation scores after BMT. However, our findings clearly demonstrate that in children undergoing BMT, at higher doses, dexmedetomidine significantly prolongs length of stay in the PACU.     

Midazolam does not reduce emergence delirium after sevoflurane anesthesia in children

Background: Behavioral disturbance in children following sevoflurane anesthesia is a relatively frequent event. The aim of this study was to evaluate whether a higher dose of preoperatively administered rectal midazolam compared with a lower would alleviate this phenomenon. Furthermore the impact of these two doses of midazolam on sedation at induction of anesthesia was compared. Methods: A total of 115 children presenting for minor surgery under anesthesia were included in the study. The children were randomized to receive rectally either 1 mg·kg⁻¹ midazolam (group H) or 0.5 mg·kg⁻¹ midazolam (group L). General anesthesia was induced with propofol or sevoflurane and maintained with 1.5% sevoflurane in the inspiratory limb. Prior to the start of surgery a regional block was performed to ensure adequate pain relief. Behavior on emergence was assessed using a three point scale. In case of severe agitation propofol was administered IV. Results: The children in group H were significantly better sedated preoperatively (P < 0.01). There was no significant difference in emergence behavior: 42.1% of children in group H compared with 36.2% of children in group L exhibited severe agitation requiring sedation with propofol (P = 0.37). However, regardless of the preoperative dose of midazolam more children under the age of 36 months (61.4%) were severely distressed at emergence compared with older children (16.7%) (P < 0.01). Conclusions: A higher dose of 1 mg·kg⁻¹ rectal midazolam results in much better sedated children on induction of anesthesia than 0.5 mg·kg⁻¹. This, however, does not result in a reduced incidence of emergence delirium after sevoflurane anesthesia. Regardless of the premedication negative behavioral changes occur more frequently in children younger than 3 years of age.     

全麻苏醒期患儿躁动风险预测模型的建立与验证

目的 建立与验证全麻苏醒期患儿躁动风险列线图预测模型,为识别躁动高风险患儿提供评估工具。方法 收集全麻手术的1～6岁患儿651例,随机分为建模组(n=459)和验证组(n=192),利用多因素logistic回归分析确定建模组全麻苏醒期患儿躁动的危险因素,构建列线图预测模型,分别使用建模组和验证组数据集对模型进行验证。结果 苏醒期发生躁动160例(建模组113例,验证组47例),躁动发生率24.58%。多因素logistic回归显示,年龄、手术科室、身体约束、麻醉方式、镇痛治疗、留置尿管是全麻苏醒期患儿躁动的影响因素(均P<0.05)。基于6个危险因素构建列线图预测模型,模型验证的校正曲线显示模型准确度良好,建模组ROC曲线下面积为0.767,验证组为0.827。结论 全麻苏醒期患儿躁动风险列线图预测模型具有良好的准确度和区分度,可为临床筛查术后躁动高危患儿提供评估工具。     

Propofol or midazolam do not reduce the incidence of emergence agitation associated with desflurane anaesthesia in children undergoing adenotonsillectomy

BACKGROUND: The aim of the study was to determine if concurrent use of short-acting sedatives would decrease the incidence of emergence agitation associated with desflurane while preserving rapid recovery. METHODS: Sixty-nine children, aged 2-9 years, who were undergoing adenotonsillectomy, were randomly assigned to three groups: (i) intravenous midazolam 0.1 mg.kg-1; (ii) propofol 2 mg.kg-1; and (iii) control. An observer blind to anaesthetic technique assessed emergence times and behaviour. Data were compared using chi-squared and ANOVA. RESULTS: Midazolam initially decreased the incidence of emergence agitation but, in the postanaesthesia care unit, significant agitation was seen in all three groups. Emergence and complete recovery were delayed in groups 1 and 2. CONCLUSIONS: The concurrent use of midazolam or propofol did not reduce the incidence of emergence agitation but did delay emergence and recovery. These agents are not recommended for reducing emergence agitation in children receiving desflurane.     

Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofol

BACKGROUND: Emergence agitation in children is frequently associated with the use of the new highly insoluble volatile anaesthetics. Rapid emergence has been cited as one of the possible causes. Propofol also permits rapid emergence from general anaesthesia but is not associated with agitation. METHODS: The emergence characteristics of children receiving sevoflurane and propofol anaesthesia were examined. After induction with sevoflurane, 53 children, aged 2-36 months, who were undergoing ambulatory surgery, were randomized to receive maintenance anaesthesia with either sevoflurane or propofol. Introperative analgesia with either 2 micro g x kg-1 of intravenous fentanyl or a caudal block with 0.25% bupivacaine was supplied according to surgical procedure. An observer blinded to anaesthetic technique recorded the time to achieve extubation and recovery and assessed emergence behaviour. Data were analysed using Wilcoxon scores, Kruskal-Wallis test, chi-square and multiple regression analysis. RESULTS: The results showed that the time to extubation and recovery were similar between the two study groups, but that emergence agitation was significantly higher in the sevoflurane group compared with the propofol group. No relationship between analgesic technique and agitation scores was found. CONCLUSIONS: Although both sevoflurane and propofol allow for rapid emergence from general anaesthesia, only sevoflurane is associated with a high incidence of emergence agitation in infants and young children. Rapid emergence does not fully explain this phenomena.     

Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia

BACKGROUND: Emergence agitation or delirium is a known phenomenon that may occur in children undergoing general anesthesia with inhaled agents. Our aim was to test the hypothesis that the addition of a small dose of ketamine at the end of sevoflurane anesthesia will result in a decrease in the incidence and severity of such phenomenon. METHODS: We performed a randomized double blind study involving 85 premedicated children 4-7 years old undergoing dental repair. Children were premedicated with acetaminophen and midazolam. Anesthesia was induced and maintained with sevoflurane in N2O/O2. Group K received ketamine 0.25 mg.kg (-1) and Group S received saline. We evaluated recovery characteristics upon awakening and during the first 30 min using the Pediatric Anesthesia Emergence Delirium scale. RESULTS: Eighty of the 85 enrolled children completed the study. There were 42 children in Group I. Emergence agitation was diagnosed in seven children in the ketamine group (16.6%) and in 13 children in the placebo group (34.2%). There was no difference in time to meet recovery room discharge criteria between the two groups. CONCLUSIONS: We conclude that the addition of ketamine 0.25 mg.kg(-1) can decrease the incidence of emergence agitation in children after sevoflurane general anesthesia.     

术前口服咪达唑仑对患儿七氟醚麻醉苏醒期躁动的影响

目的评价术前口服咪达唑仑对患儿七氟醚麻醉苏醒期躁动的影响。方法选择择期七氟醚麻醉下行扁桃体/腺样体切除术的患儿60例,男34例,女26例,年龄2~7岁,ASAⅠ或Ⅱ级,将入选患儿随机分为低剂量咪达唑仑组(M1组)、高剂量咪达唑仑组(M2组)和对照组(C组),每组20例。麻醉前30min分别给予M1组和M2组患儿分别口服咪达唑仑0.5 mg/kg和0.75 mg/kg,口服10%葡萄糖混合液5ml。吸入8%七氟醚行麻醉诱导,术中吸入七氟醚及静脉泵注瑞芬太尼维持麻醉。记录患儿分离焦虑量表(PSAS)评分、麻醉苏醒谵妄量表(PAED)评分和FLACC疼痛评分,并记录拔除气管导管时间和滞留PACU时间。结果 C组患儿的分离焦虑发生率明显高于其他两组(P0.05)。三组苏醒期躁动发生率、最高PAED评分、FLACC疼痛评分以及拔除气管导管时间差异均无统计学意义。M2组滞留PACU时间明显长于其他两组(P0.05)。结论术前口服咪达唑仑0.5mg/kg或0.75mg/kg能有效减轻患儿术前分离焦虑,但不能减少七氟醚麻醉苏醒期躁动的发生,咪达唑仑0.75mg/kg会延长PACU滞留时间。     

Effect of propofol on emergence behavior in children after sevoflurane general anesthesia

BACKGROUND: Emergence agitation (EA) is a postoperative behavior that may occur in children undergoing general anesthesia with inhaled agents. OBJECTIVES: The aim of the present study was to assess the effect of propofol administered at the end of sevoflurane anesthesia on the incidence and severity of EA in children undergoing magnetic resonance imaging (MRI). METHODS: Eighty-four children, 2-7 years old, undergoing MRI were enrolled in this randomized double-blind study. No sedative premedication was administered prior to anesthesia induction. Anesthesia was induced and maintained with sevoflurane in N(2)O/O(2). Group P received propofol 1 mg.kg(-1) and group S received saline. Pediatric Anesthesia Emergence Delirium scale (PAEDs) was used to evaluate recovery characteristics upon awakening and during the first 30 min after emergence from anesthesia. Children with PAEDs >16 were considered agitated. EA was analyzed using the Mann-Whitney U-test. Demographic data and other side effects were analyzed using the Student's t-test. RESULTS: Eighty-three children completed the study. There were 42 children in group P. EA was diagnosed in two children in the propofol group (4.8%) and in 11 children in the placebo group (26.8%, P < 0.05). Time to achieving postanesthesia care unit discharge criteria was not different between the two groups. CONCLUSIONS: The addition of propofol 1 mg.kg(-1) can significantly decrease the incidence of EA after sevoflurane general anesthesia in children undergoing nonpainful procedures.