Desflurane anesthesia after sevoflurane inhaled induction reduces severity of emergence agitation in children undergoing minor ear-nose-throat surgery compared with sevoflurane induction and maintenance

Emergence agitation may occur after general anesthesia with volatile anesthetics in children. We designed this study to examine the emergence behavior of children undergoing ear-nose-throat surgery after sevoflurane induction and desflurane maintenance versus both sevoflurane induction and maintenance using a recently published Pediatric Anesthesia Emergence Delirium (PAED) scale. In 38 premedicated children aged 12 mo to 7 yr mask induction with sevoflurane was performed and they were randomly assigned to receive either sevoflurane (n = 19) or desflurane (n = 19) for maintenance of general anesthesia. Time to tracheal extubation, modified Aldrete score, emergence behavior, recovery complications, and pain scores were assessed. The PAED scale showed a significant advantage for desflurane (6 [0-15] versus 12 [2-20], maximum total score of 20 for severe agitation). Time to extubation was significantly shorter with desflurane than with sevoflurane (5.4 +/- 1.4 versus 13.4 +/- 1.8 min). The modified Aldrete score on arrival in the postanesthesia care unit (PACU) was significantly lower in children receiving sevoflurane for maintenance. Time to discharge from PACU to normal ward and the incidence of adverse effects were not significantly different between the groups. In conclusion, the use of desflurane for maintenance of anesthesia after sevoflurane induction in children is associated with less severe emergence agitation and faster emergence times.     

Emergence delirium and postoperative pain in children undergoing adenotonsillectomy: a comparison of propofol vs sevoflurane anesthesia

Background: Emergence delirium (ED) is a frequent postoperative complication in young children undergoing ENT procedures and it may be exacerbated by sevoflurane anesthesia whereas propofol maintenance has been suggested to decrease the incidence of ED. The aim of this randomized, prospective, double‐blind study was to evaluate the effect of sevoflurane vs propofol anesthesia on the quality of recovery after adenotonsillectomy. Methods: Forty‐two patients were randomized to maintenance with either propofol or sevoflurane for adenotonsillectomy. At the conclusion of surgery, patients were extubated awake. ED and pain were assessed using the Pediatric Anesthesia Emergence Delirium (PAED) and the Children’s Hospital of Eastern Ontario Scale (CHEOPS), respectively. Higher PAED scores (0–20) indicate greater severity of ED. Nursing and parental satisfaction, hospital length of stay, postoperative nausea and vomiting (PONV), anesthetic complications, and subsequent emergency room admissions were also assessed. Results: Median PAED score was 14 in the propofol group and 17 in the sevoflurane group (NS). Propofol was associated with less pain medication required during recovery and a lower incidence of PONV (5.3% vs 36.8%, P < 0.05). Nursing and parental satisfaction as well as time spent in recovery room was similar for the two groups. Conclusion: Propofol anesthesia does not influence agitation after adenotonsillectomy, as measured by the PAED score. A PAED score of ≥10 was not useful in identifying patients with ED. However, propofol maintenance is associated with less need for pain medication in the recovery room and a lower incidence of PONV compared to sevoflurane anesthesia.     

The effect of magnesium sulphate infusion on the incidence and severity of emergence agitation in children undergoing adenotonsillectomy using sevoflurane anaesthesia

This randomised, controlled, double‐blind study investigated the effects of intra‐operative magnesium sulphate administration on the incidence of emergence agitation in children undergoing adenotonsillectomy using sevoflurane anaesthesia. Seventy children were randomly allocated to receive a 30 mg.kg^?1 bolus of intravenous magnesium sulphate after induction of anaesthesia followed by a continuous infusion of 10 mg.kg^?1.h^?1 or an equal volume of saline 0.9%. All children received titrated sevoflurane anaesthesia adjusted to maintain haemodynamic stability. The Pediatric Anesthesia Emergence Delirium scale and the Children's Hospital of Eastern Ontario Score were used for the assessment of postoperative emergence agitation and pain, respectively. Emergence agitation was more common in the control group than in the magnesium group (23 (72%) and 12 (36%), respectively (p = 0.004)), with a relative risk of 0.51 (95% CI 0.31–0.84), an absolute risk reduction of 0.35 (95% CI 0.10–0.54), and number needed to treat of 3 (95% CI 2–9). Postoperative pain scores were comparable in the two groups. Magnesium sulphate reduces the incidence and severity of emergence agitation in children undergoing adenotonsillectomy using sevoflurane anaesthesia and is not associated with increased postoperative side‐effects or delayed recovery.     

Efeitos de cetamina e midazolam sobre a incidência de agitação pós‐anestesia com sevoflurano em crianças submetidas ao bloqueio caudal: estudo randomizado

Background and objectivesEmergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia.Methods62 American Society of Anesthesiologists patient classification status I children, aged 2–7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75 mL kg⁻¹, 0.25% bupivacaine. At the end of the surgery, ketamine 0.25 mg kg⁻¹, midazolam 0.03 mg kg⁻¹ and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale.Results and conclusionsModified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow‐up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia.     

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.     

A comparison of two different doses of ketamine with midazolam and midazolam alone as oral preanaesthetic medication on recovery after sevoflurane anaesthesia in children

BACKGROUND: This investigation prospectively evaluated the effect of oral premedication of two different doses of ketamine with midazolam and midazolam alone on the recovery of children after sevoflurane anaesthesia. METHODS: In a randomized, double-blind study, 79 children (aged 1-8 years, ASA physical status I or II) were assigned to receive one of three premedications in a volume of 0.5 ml x kg(-1): group 1 received midazolam 0.5 mg x kg(-1) (MD); group 2 received midazolam 0.5 mg x kg(-1) with ketamine 1.8 mg x kg(-1) (MK-1); and group 3 received midazolam 0.5 mg x kg(-1) with ketamine 3 mg x kg(-1) (MK-2). The reactions of the children during administration were noted. Anaesthesia was induced by facemask with incremental sevoflurane administration. All children received alfentanil (15 micro g x kg(-1)). Tracheal intubation was facilitated by mivacurium (0.2 mg x kg(-1)). Anaesthesia was maintained with sevoflurane and an additional dose of alfentanil, if necessary. During recovery, the time interval between discontinuation of anaesthesia and arousal (spontaneous ventilation, extubation) were recorded. RESULTS: Emergence (spontaneous ventilation, extubation) and recovery times (discharge, Aldrete score=9) did not differ significantly between groups (P=0.24, P=0.59 and P=0.145, respectively). CONCLUSIONS: The combination of midazolam and ketamine as oral preanaesthetic medication did not significantly affect the recovery time of children after sevoflurane anaesthesia.     

The optimal bolus dose of alfentanil for tracheal intubation during sevoflurane induction without neuromuscular blockade in day-case anaesthesia

Background: The purpose of this study was to determine the optimal bolus dose of alfentanil required to provide successful intubating conditions following inhalation induction of anaesthesia using 5% sevoflurane and 60% nitrous oxide without neuromuscular blockade in adult day-case anaesthesia.
Methods: Twenty-four adults, aged 18–60 years, undergoing general anaesthesia for short ambulatory surgery were enroled into the study. After vital capacity induction, with sevoflurane 5% and 60% nitrous oxide in oxygen, pre-determined dose of alfentanil was injected over 30 s. The dose of alfentanil was determined by modified Dixon's up-and-down method (2 μg/kg as a step size). Ninety seconds after the end of bolus administration of alfentanil, the trachea was intubated. Systolic blood pressure, heart rate and SpO₂ were recorded at anaesthetic induction, before, 1 min and 3 min after intubation.
Results: The bolus dose of alfentanil for successful tracheal intubation was 10.7±2.1 μg/kg in 50% of patients during inhalation induction. From probit analysis, 50% effective dose (ED₅₀) and ED₉₅ values (95% confidence limits) of alfentanil were 10.7 μg/kg (8.0–12.9 μg/kg) and 14.9 μg/kg (12.9–31.1 μg/kg), respectively.
Conclusions: Using the modified Dixon's up-and-down method, the bolus dose of alfentanil for successful tracheal intubation was 10.7±2.1 μg/kg in 50% of adult patients during inhalation induction using 5% sevoflurane and 60% nitrous oxide in oxygen without neuromuscular blocking agent in day-case anaesthesia.     

Quality of recovery in children: sevoflurane versus propofol

BACKGROUND: Sevoflurane, with its low pungency and low blood and tissue solubility, is an attractive anaesthetic in paediatric outpatient surgery. Propofol-anaesthesia is recognised for its rapid and clear-headed emergence. This study was designed to compare emergence and recovery characteristics of sevoflurane and propofol anaesthesia for tonsillectomy in children. METHODS: Children aged 3-10 years, undergoing elective tonsillectomy, were randomly assigned to receive propofol (n=25, induction with 3 mg x kg(-1), maintenance with 100-250 microg x kg(-1) min(-1)) or sevoflurane anaesthesia (n=25, induction 7 vol.%, maintenance 2-3 vol.%). Tracheal intubation was performed with alfentanil 20 microg x kg(-1) and atracurium 0.5 mg x kg(-1). Ventilation was controlled to maintain normocapnia and all patients received N2O/O2 (60:40 vol.%) for induction and maintenance of anaesthesia. At the end of surgery infiltration of the operative sites with bupivacaine 2 mg x kg(-1) was provided for postoperative analgesia. Emergence, recovery, discharge times, and incidence of side effects were compared between the two groups. RESULTS: Time to extubation (14 vs 15 min), time to response to simple verbal command (21 vs 21 min) and time to discharge from the recovery room (45 vs 50 min) were similar in the sevoflurane and propofol groups, respectively. There was a significantly greater incidence of postoperative agitation in the sevoflurane group (46%) compared with the propofol group (9%) (P=0.008). This did not, however, delay discharge from the recovery room. The incidence of nausea and vomiting was not significantly different (8% vs 0%; P=0.49). CONCLUSION: In children, recovery from anaesthesia with sevoflurane results in a higher incidence of agitation compared with propofol.     

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。     

Prophylactic use of midazolam or propofol at the end of surgery may reduce the incidence of emergence agitation after sevoflurane anaesthesia

Sevoflurane is associated with a high incidence of emergence agitation in children. Midazolam and propofol have been examined with the aim of reducing emergence agitation after sevoflurane anaesthesia. However the effect of both drugs on emergence agitation is still controversial. Therefore we designed this study to measure the effect of midazolam or propofol at the end of surgery on emergence agitation during the recovery period. One hundred and one children, aged one to 13 years, undergoing strabismus surgery were enrolled in this randomised double-blind study. Anaesthesia was induced and maintained with sevoflurane in N2O/O2. Children were randomly assigned to receive midazolam 0.05 mg/kg (group M, n = 35), propofol 1 mg/kg (group P, n = 31) or saline (group S, n = 35). A four-point scale was used to evaluate recovery characteristics upon awakening and during the first hour after emergence from anaesthesia. The incidence of emergence agitation in group M was 42.9% (15/35), in group P 48.4% (15/31) and in group S 74.3% (26/35). The incidence of emergence agitation in groups M and P was significantly less than in group S. The emergence time was prolonged for patients in groups M and P compared to group S. There was no significant difference in the incidence of emergence agitation or in emergence times between the groups P and M. We conclude that propofol or midazolam administration before the end of surgery may be effective in reducing the incidence of emergence agitation in children undergoing strabismus surgery under sevoflurane anaesthesia.     

经皮穴位电刺激对小儿扁桃体切除术后躁动的影响

目的 评价经皮穴位电刺激(TEAS)复合全麻对小儿扁桃体切除术后躁动及血流动力学的影响.方法 择期行扁桃体切除手术患儿60例,随机均分为经皮穴位电刺激组(T组)和对照组(C组),T组患儿予持续TEAS两侧合谷和内关穴位,两组麻醉诱导后全凭静脉维持麻醉,术后若患儿出现不能安慰的躁动,则静脉给予芬太尼0.5 μg/kg(T组)或1 μg/kg(C组).于入室时、插管时、拔管时、拔管后10 min以酶联免疫法测定两组患者血浆、肾上腺素(E)、去甲肾上腺素(NE)、β-内啡肽(β-EP)的变化.记录拔管时,拔管后5、10、15、30 min小儿麻醉后躁动(PAED)评分和疼痛评分(CHIPPS).结果 与入室时比较,插管时、拔管时、拔管后10 min两组患者E、NE均显著升高(P＜0.05),且C组显著高于T组(P＜0.05);T组插管时、拔管时、拔管后10 min时β-EP高于入室时和C组(P＜0.05);T组患者拔管后各时点PAED和CHIPPS均显著低于C组(P＜0.05).结论 TEAS可减少小儿扁桃体切除术后躁动的发生率.     

Ondansetron does not modify emergence agitation in children

In this prospective, placebo-controlled study, we evaluated the effect of prophylactic ondansetron therapy on emergence agitation of children who underwent minor surgery below the umbilicus. Seventy children aged one to six years and American Society of Anesthesiologists physical status I were studied. Children were premedicated with midazolam rectally and were randomly assigned to receive either ondansetron (Group O) or placebo (Group P) in combination with caudal anaesthesia. Children in Group O received intravenous ondansetron (0.1 mg/kg for children weighing < 40 kg, 4 mg for children weighing > 40 kg) and Group P (n = 35) received normal saline 2 ml following anaesthesia induction with sevoflurane. Airway management was provided with LMA-Proseal without muscle relaxation and anaesthesia maintenance was provided with a 60:40 N2O:O2 mixture and sevoflurane. Emergence agitation was evaluated with a ten point scale and pain level was assessed every 10 minutes for the first 30 minutes after admission to the recovery room. There were no significant differences between the placebo and ondansetron groups with respect to demographic, anaesthetic and surgical details. Incidences of emergence agitation in ondansetron and placebo groups were similar (32.4% and 30.3% at 10 minutes respectively). Mean modified Children's Hospital of Eastern Ontario pain scale scores and mean ten-point scale scores and emergence agitation incidences decreased similarly after 10 minutes in both groups. Ready time for discharge was similar between the groups. Agitated patients had significantly increased ready time for discharge compared to non-agitated patients (P = 0.001). Prophylactic intravenous ondansetron administration does not reduce emergence agitation comparing to placebo after sevoflurane anaesthesia.     

Oral ketamine premedication can prevent emergence agitation in children after desflurane anaesthesia

BACKGROUND: The purpose of the present study was to determine whether oral ketamine premedication affected the incidence of emergence agitation in children. METHODS: Thirty minutes before induction of anaesthesia, 80 children who were undergoing adenotonsillectomy with or without bilateral myringotomy and insertion of tubes received either ketamine 6 mg.kg(-1) per oral in group K or sour cherry juice alone in group C. Anaesthesia was maintained with desflurane. Emergence and recovery times were recorded. Tramadol was used for postoperative analgesia. Fentanyl (1 microg.kg(-1)) was administered for the treatment of emergence agitation or severe pain that still continued after tramadol administration. Postoperative behaviour was evaluated using a 5-point agitation scale. RESULTS: The incidence of emergence agitation was 56% in group C, and 18% in group K (P = 0.001). There was no significant difference with respect to emergence times except from time to eye opening that was significantly longer in group K (P < 0.0001). CONCLUSION: Oral ketamine premedication reduced the incidence of postanaesthesia emergence agitation in children without delaying recovery.     

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.     

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。     

Volatile induction and maintenance (VIMA) versus total intravenous anaesthesia (TIVA) for minor gynaecological procedures

We compared the techniques of volatile induction and maintenance (VIMA) and total intravenous anaesthesia (TIVA) in various aspects. Patients undergoing spontaneous respiration-general anaesthesia were randomised into two groups; Group P received iv fentanyl 1 μg/kg and propofol 2 mg/kg for induction followed by propofol 10 mg/min as required. Group S received vital capacity induction with sevoflurane and were maintained on 66% N₂O in O₂ with sevoflurane 2%. Induction times, complications and recovery times were recorded. Visual analogue scores for pain and satisfaction were assessed. The two groups did not differ significantly in emergence times or VAS scores for pain and satisfaction but more complications like apnoea and injection pain were encountered during TIVA compared to VIMA. Our results suggest that both techniques are comparable in efficacy for providing anaesthesia in minor gynaecological surgery with swift induction, good recovery and minimal postoperative complications.     

Effects of fentanyl on the incidence of emergence agitation in children receiving desflurane or sevoflurane anaesthesia

BACKGROUND AND OBJECTIVE: In children, emergence agitation frequently complicates sevoflurane and desflurane anaesthesia. The effect of intravenous fentanyl 2.5 microg kg(-1) was examined on the incidence of emergence agitation in children who received desflurane or sevoflurane after midazolam premedication and intravenous thiopental induction. METHODS: One hundred and twenty children (2-7 yr) undergoing adenoidectomy or tonsillectomy, or both, were studied. All children were premedicated orally with midazolam 0.5 mg kg(-1). After intravenous induction with thiopental and atracurium to facilitate endotracheal intubation, patients were randomly assigned to one of four groups: Patients in Groups 1 and 3 received physiological saline solution, whereas patients in Groups 2 and 4 received intravenous fentanyl 2.5 microg kg(-1) during induction. Anaesthesia was maintained with sevoflurane in Groups 1 and 2 and with desflurane in Groups 3 and 4. After discontinuation of the volatile anaesthetic, the times to tracheal extubation and response to verbal stimuli (emergence time), and emergence behaviours were recorded. RESULTS: The time to tracheal extubation was significantly shorter in Groups 3 (5.2+/-1.7 min) and (6.4+/-2.1 min) than in Groups 1 (8.1+/-2.1 min) (P = 0.0001 and 0.006, respectively) and 2 (8.8+/-1.9 min) (P = 0.0001). The emergence time was significantly shorter in Group 3 (10.0+/-3.9 min) than in Groups 1 (13.8+/-4.9 min) (P = 0.017) and 2 (14.9+/-4.1 min) (P = 0.003). The incidence rate of severe agitation was 13% in Groups 1 and 3, and 7 and 10% in Groups 2 and 4, respectively (P > 0.05). CONCLUSIONS: After midazolam premedication and intravenous induction of anaesthesia with thiopental administration of intravenous fentanyl 2.5 microg kg(-1) did not provide any clinically significant benefit on emer gence agitation in children who receive sevoflurane or desflurane anaesthesia.     

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.     

Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block

Background: In this prospective randomized study, the authors compared the analgesic effect of a fascia iliaca compartment (FIC) block with that of intravenous (i.v.) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture.
Methods: The 40 patients were randomly assigned to one of two groups, namely, the FIC group (fascia iliaca compartment block, n =20) and the IVA group (intravenous analgesia with alfentanil, n =20). Group IVA patients received a bolus dose of i.v. alfentanil 10 μg/kg, followed by a continuous infusion of alfentanil 0.25 μg/kg/min starting 2 min before the spinal block, and group FIC patients received a FIC block with 30 ml of ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual analogue pain scale (VAS) scores, time to achieve spinal anaesthesia, quality of patient positioning, and patient acceptance were compared.
Results: VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1–4) vs. 3.5 (2–6), P =0.001], and the mean (± SD) time to achieve spinal anaesthesia was shorter in the FIC group (6.9 ± 2.7 min vs. 10.8 ± 5.6 min; P =0.009). Patient acceptance (yes/no) was also better in the FIC group (19/1) than in the IVA group (12/8)( P =0.008).
Conclusions: An FIC block is more efficacious than i.v. alfentanil in terms of facilitating the lateral position for spinal anaesthesia in elderly patients undergoing surgery for femoral neck fractures.     

Sevoflurane provides better recovery than propofol plus fentanyl in anaesthesia for day-care surgery

To compare ease of maintenance and recovery characteristics of sevoflurane and propofol plus fentanyl in day-care anaesthesia, 60 outpatients undergoing elective surgery of up to 3 h duration were randomized to receive sevoflurane or propofol as their primary anaesthetic. Induction was always carried out with propofol, but a fentanyl bolus 5 microg kg-1 was added in the propofol group. Anaesthesia was supplemented with up to 70% N2O. Significantly shorter times to extubation (10.03 min +/- 3.2 SD vs. 17.2 +/- 7.3; P < 0.001) and emergence (10.4 +/- 3.1 vs. 16.8 +/- 6.4; P < 0.001) were observed in the sevoflurane group. Patients treated with sevoflurane felt less confused, showed better performances in the digit symbol substitution test and achieved higher modified Aldrete scores sooner in the post-operative course. Maintenance of anaesthesia with sevoflurane produces faster emergence and recovery than propofol plus fentanyl after anaesthesia of short to intermediate duration.