Maintenance and recovery characteristics after sevoflurane or propofol during ambulatory surgery in children with epidural blockade

Comparison of postoperative pain in children after maintenance anaesthesia with propofol or sevoflurane: a systematic review and meta-analysis

BACKGROUND

Propofol and sevoflurane are two of the most commonly used anaesthetics for paediatric surgery. Data from some clinical trials suggest that postoperative pain incidence is lower when propofol is used for maintenance of anaesthesia compared with sevoflurane, although this is not clear.

METHODS

This meta-analysis compared postoperative pain following maintenance of anaesthesia with propofol or sevoflurane in paediatric surgeries. PubMed Medline, Embase, Scopus, Web of Science and Cochrane Library were searched for randomised controlled trials (RCTs) that compared postoperative pain between sevoflurane and propofol anaesthesia in children. After quality assessment, a meta-analysis was carried out using bias-adjusted inverse heterogeneity methods, heterogeneity using I2 and publication bias using Doi plots.

RESULTS

In total, 13 RCTs with 1174 children were included. The overall synthesis suggested nearly two-fold higher odds of overall postoperative pain in the sevoflurane group compared with the propofol group (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.12-3.15, I2=58.2%). Further, children in the sevoflurane group had higher odds of having higher pain scores (OR 3.18, 95% CI 1.83-5.53, I2=20.9%), and a 60% increase in the odds of requiring postoperative rescue analgesia compared with propofol (OR 1.60, 95% CI 0.89-2.88, I2=58.2%).

CONCLUSIONS

Children maintained on inhalational sevoflurane had higher odds of postoperative pain compared with those maintained on propofol. The results also suggest that sevoflurane is associated with higher odds of needing postoperative rescue analgesia compared with propofol.

REGISTRATION

The protocol for this systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO) with registration ID CRD42023445913.

The Safety of Propofol Versus Sevoflurane for General Anesthesia in Children: A Meta-Analysis of Randomized Controlled Trials

Background

Propofol and sevoflurane are the most used anesthetics for pediatric surgery. Emergence agitation, postoperative nausea and vomiting and postoperative pain are the primary adverse effect of these general anesthetics. Many clinical studies had compared the safety of propofol and sevoflurane in pediatric surgery, but the results were controversial.

Objectives

To evaluate the evidence surrounding the safety of propofol versus sevoflurane for general anesthesia in children.

Methods

Databases including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data and Vip Data were searched to collect relevant articles. Trials were strictly selected according to previously defined inclusion and exclusion criteria. RevMan 5.3 software was used for meta-analyses.

Results

Twenty randomized controlled trials recruiting 1,550 children for general anesthesia were included, with overall low-moderate methodological quality. There was evidence that compared with sevoflurane anesthesia, propofol anesthesia significantly decreased the incidence of emergence agitation (OR = 4.99, 95% CI, 3.67–6.80; P < 0.00001), postoperative nausea and vomiting (OR = 1.91, 95% CI, 1.27–2.87; P  =  0.002) and postoperative pain (OR = 1.72, 95% CI, 1.11–2.64; P = 0.01) in children. However, patients who received sevoflurane tended to have shorter times to eye opening (MD = −2.58, 95% CI, −2.97– −2.19; P < 0.00001) and times to extubation (MD = −1.42, 95% CI, −1.81– −1.02; P < 0.00001).

Conclusions

This review reveals that the children who received propofol anesthesia had the lower risks of emergence agitation, postoperative nausea and vomiting and postoperative pain when compared with sevoflurane anesthesia. But the children who received sevoflurane recovered slightly faster than those received propofol. Considering the limitations of the included studies, better methodological quality and large controlled trials are expected to further quantify the safety of propofol and sevoflurane for general anesthesia in children.

Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis

BACKGROUND

Emergence delirium is a common complication in paediatric anaesthesia associated with significant morbidity. Total intravenous anaesthesia (TIVA) and intra-operative dexmedetomidine as an adjuvant to sevoflurane anaesthesia can both reduce the incidence of emergence delirium compared with sevoflurane alone, but no studies have directly compared their relative efficacy.

OBJECTIVE

The study objective was to compare the effects of TIVA and dexmedetomidine on the incidence of paediatric emergence delirium.

STUDY DESIGN

The current study is a systematic review and network meta-analysis (NMA) of randomised controlled trials.

DATA SOURCES

We conducted a systematic search of 12 databases including Medline (Ovid) and Web of Science (Clarivate Analytics) from their respective inception to December 2020.

ELIGIBILITY

Inclusion criteria were randomised controlled trials of paediatric patients undergoing general anaesthesia using sevoflurane, sevoflurane with dexmedetomidine or TIVA. Data were extracted by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and analysed using NMA methodology. Risk ratios and 95% credible intervals (CrI) were calculated for all outcomes [emergence delirium, postoperative nausea and vomiting (PONV), and time to emergence and extubation]. The protocol was registered with PROSPERO (CRD42018091237).

RESULTS

The systematic review returned 66 eligible studies comprising 5257 patients with crude median emergence delirium incidences of 12.8, 9.1 and 40% in the dexmedetomidine with sevoflurane, TIVA and sevoflurane alone groups, respectively. NMA indicated that compared with TIVA, sevoflurane with adjuvant dexmedetomidine decreased the incidence of emergence delirium without statistical difference (risk ratio 0.88, 95% CrI 0.61 to 1.20, low quality of evidence), but resulted in a higher incidence of PONV (risk ratio: 2.3, 95% CrI 1.1 to 5.6, low quality of evidence).

CONCLUSION

Clinical judgement, considering the patient's risk factors for the development of clinically significant outcomes such as emergence delirium and PONV, should be used when choosing between TIVA and sevoflurane with adjuvant dexmedetomidine. These findings are limited by the low quality of evidence (conditional recommendation).

Hot Topics in Safety for Pediatric Anesthesia

Anesthesiology is one of the leading medical specialties in patient safety. Pediatric anesthesiology is inherently higher risk than adult anesthesia due to differences in the physiology in children. In this review, we aimed to describe the highest yield safety topics for pediatric anesthesia and efforts to ameliorate risk. Conclusions: Pediatric anesthesiology has made great strides in patient perioperative safety with initiatives including the creation of a specialty society, quality and safety committees, large multi-institutional research efforts, and quality improvement initiatives. Common pediatric peri-operative events are now monitored with multi-institution and organization collaborative efforts, such as Wake Up Safe.

Respiratory and hemodynamic perioperative adverse events in intravenous versus inhalational induction in pediatric anesthesia: A systematic review and meta-analysis

Perioperative respiratory and hemodynamic adverse events are still a cause of morbidity and mortality in pediatric anesthesia. It has been suggested that volatile agents might be associated with more respiratory adverse events compared to intravenous agents (eg, propofol), which have been associated with a higher risk of bradycardia compared to volatile agents. We performed a systematic review and meta-analysis to evaluate the risk of perioperative hemodynamic and respiratory adverse events, comparing intravenous induction with inhalational induction in pediatric anesthesia. We searched PubMed, Embase, and Medline up to February 12, 2020. Randomized controlled trials were included. A quality assessment was carried out using a modified version of the "Cochrane Risk of Bias Tool for Randomized Controlled Trials." Of the 1602 applicable publications, four were included in the final review. Two studies found no significant differences in perioperative respiratory or hemodynamic adverse events. Two studies found a higher risk of respiratory perioperative adverse events in inhalation versus intravenous induction, with a relative risk varying from 1.64 to 3.83. Data were heterogenous, and pooled estimates may not be reliable. The present systematic review and meta-analysis revealed no significant difference in the occurrence of perioperative respiratory adverse events between inhalation and intravenous induction. More respiratory adverse events during and after inhalation induction were found, in particular in children with multiple risk factors for respiratory adverse events. This did not reach significance. Future research should include a large randomized controlled trial comparing inhalation and intravenous induction with respiratory and hemodynamic adverse events as primary outcome and adequately blinded outcome assessors.

Recovery with Propofol Anesthesia in Children Undergoing Cleft Palate Repair Compared with Sevoflurane Anesthesia

Background

Nowadays, propofol total intravenous anesthesia (propofol TIVA) is a very attractive choice for routine pediatric anesthesia practice.

Objectives

To compare propofol- vs. sevoflurane-based anesthesia for pediatrics undergoing cleft palate repair in emergence characteristics and respiratory adverse effects.

Methods

Eighty infants, aged from six months to one year, scheduled for cleft palate repair surgery, were randomly divided into two groups (40 patients each). The group I received general anesthesia induced with intravenous propofol 2.5 mg/kg, 0.1 mg/kg of lidocaine, fentanyl one µg/kg and cisatracurium 0.15 mg/kg, and maintained by a continuous infusion of propofol 9 mg/kg/hr and cisatracurium 3 µg/kg/hr. While in the group II, general anesthesia induced by O₂/sevoflurane, intravenous fentanyl one µg/kg and cisatracurium 0.15 mg/kg then the maintenance was carried out by O₂/air, sevoflurane 2 MAC, and cisatracurium three µg/kg/hr. Postoperative FLACC behavioral pain assessment Scale, modified Hannallah score, postoperative laryngeal spasm incidence, the recovery time, time to extubation, and postoperative complication were recorded.

Results

The quality of emergence was assessed by modified Hannallah score, there was a significant decrease in the number of patients developed agitation after propofol TIVA in comparison to sevoflurane anesthesia (P < 0.001) with a significant decrease in the number of patients developed postoperative laryngeal spasm (P < 0.047). On the other hand, a significantly prolonged time of extubation was observed in the propofol TIVA group (P < 0.001).

Conclusions

Propofol TIVA regimen was the more peaceful recovery approach with less perioperative respiratory complications than sevoflurane-based anesthesia in infants undergoing cleft palate repair surgery.

Emergence agitation in children: risk factors, prevention, and treatment

Emergence agitation (EA) in children is a major postoperative issue that increases the risk of patient self-harm, places a burden on nursing staff, and reduces parent satisfaction with treatment. Risk factors for EA include age, preoperative anxiety, patient personality, pain, anesthesia method, and surgical procedure. Sevoflurane and desflurane are widely used anesthetics due to their low blood/gas partition coefficients, but they have recently been posited as a cause of EA in children. The perioperative administration of opioids, midazolam, ketamine, alpha-2 agonist sedatives, and nonsteroidal anti-inflammatory drugs has demonstrated efficacy in the prevention and treatment of EA. Maintenance of anesthesia using propofol has also been shown to prevent EA. In children, anesthesia methods that are unlikely to cause EA should be selected, with the prompt adminstration of appropriate treatment in cases of EA.

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children

BACKGROUND

Sevoflurane is an inhaled volatile anaesthetic that is widely used in paediatric anaesthetic practice. Since its introduction, postoperative behavioural disturbance known as emergence agitation (EA) or emergence delirium (ED) has been recognized as a problem that may occur during recovery from sevoflurane anaesthesia. For the purpose of this systematic review, EA has been used to describe this clinical entity. A child with EA may be restless, may cause self-injury or may disrupt the dressing, surgical site or indwelling devices, leading to the potential for parents to be dissatisfied with their child's anaesthetic. To prevent such outcomes, the child may require pharmacological or physical restraint. Sevoflurane may be a major contributing factor in the development of EA. Therefore, an evidence-based understanding of the risk/benefit profile regarding sevoflurane compared with other general anaesthetic agents and adjuncts would facilitate its rational and optimal use.

OBJECTIVES

To compare sevoflurane with other general anaesthetic (GA) agents, with or without pharmacological or non-pharmacological adjuncts, with regard to risk of EA in children during emergence from anaesthesia. The primary outcome was risk of EA; secondary outcome was agitation score.

SEARCH METHODS

We searched the following databases from the date of inception to 19 January 2013: CENTRAL, Ovid MEDLINE, Ovid EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost), Evidence-Based Medicine Reviews (EBMR) and the Web of Science, as well as the reference lists of other relevant articles and online trial registers.

SELECTION CRITERIA

We included all randomized (or quasi-randomized) controlled trials investigating children < 18 years of age presenting for general anaesthesia with or without surgical intervention. We included any study in which a sevoflurane anaesthetic was compared with any other GA, and any study in which researchers investigated adjuncts (pharmacological or non-pharmacological) to sevoflurane anaesthesia compared with no adjunct or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the databases, decided on inclusion eligibility of publications, ascertained study quality and extracted data. They then resolved differences between their results by discussion. Data were entered into RevMan 5.2 for analyses and presentation. Comparisons of the risk of EA were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Sevoflurane is treated as the control anaesthesia in this review. Sensitivity analyses were performed as appropriate, to exclude studies with a high risk of bias and to investigate heterogeneity.

MAIN RESULTS

We included 158 studies involving 14,045 children. Interventions to prevent EA fell into two broad groups. First, alternative GA compared with sevoflurane anaesthesia (69 studies), and second, use of an adjunct with sevoflurane anaesthesia versus sevoflurane without an adjunct (100 studies). The overall risk of bias in included studies was low. The overall Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) assessment of the quality of the evidence was moderate to high. A wide range of EA scales were used, as were different levels of cutoff, to determine the presence or absence of EA. Some studies involved children receiving potentially inadequate or no analgesia intraoperatively during painful procedures.Halothane (RR 0.51, 95% CI 0.41 to 0.63, 3534 participants, high quality of evidence) and propofol anaesthesia were associated with a lower risk of EA than sevoflurane anaesthesia. Propofol was effective when used throughout anaesthesia (RR 0.35, 95% CI 0.25 to 0.51, 1098 participants, high quality of evidence) and when used only during the maintenance phase of anaesthesia after sevoflurane induction (RR 0.59, 95% CI 0.46 to 0.76, 738 participants, high quality of evidence). No clear evidence was found of an effect on risk of EA of desflurane (RR 1.46, 95% CI 0.92 to 2.31, 408 participants, moderate quality of evidence) or isoflurane (RR 0.76, 95% CI 0.46 to 1.23, 379 participants, moderate quality of evidence) versus sevoflurane.Compared with no adjunct, effective adjuncts for reducing the risk of EA during sevoflurane anaesthesia included dexmedetomidine (RR 0.37, 95% CI 0.29 to 0.47, 851 participants, high quality of evidence), clonidine (RR 0.45, 95% CI 0.31 to 0.66, 739 participants, high quality of evidence), opioids, in particular fentanyl (RR 0.37, 95% CI 0.27 to 0.50, 1247 participants, high quality of evidence) and a bolus of propofol (RR 0.58, 95% CI 0.38 to 0.89, 394 participants, moderate quality of evidence), ketamine (RR 0.30, 95% CI 0.13 to 0.69, 231 participants, moderate quality of evidence) or midazolam (RR 0.57, 95% CI 0.41 to 0.81, 116 participants, moderate quality of evidence) at the end of anaesthesia. Midazolam oral premedication (RR 0.81, 95% CI 0.59 to 1.12, 370 participants, moderate quality of evidence) and parental presence at emergence (RR 0.91, 95% CI 0.51 to 1.60, 180 participants, moderate quality of evidence) did not reduce the risk of EA.One or more factors designated as high risk of bias were noted in less than 10% of the included studies. Sensitivity analyses of these studies showed no clinically relevant changes in the risk of EA. Heterogeneity was significant with respect to these comparisons: halothane; clonidine; fentanyl; midazolam premedication; propofol 1 mg/kg bolus at end; and ketamine 0.25 mg/kg bolus at end of anaesthesia. With investigation of heterogeneity, the only clinically relevant changes to findings were seen in the context of potential pain, namely, the setting of adenoidectomy/adenotonsillectomy (propofol bolus; midazolam premedication) and the absence of a regional block (clonidine).

AUTHORS' CONCLUSIONS

Propofol, halothane, alpha-2 agonists (dexmedetomidine, clonidine), opioids (e.g. fentanyl) and ketamine reduce the risk of EA compared with sevoflurane anaesthesia, whereas no clear evidence shows an effect for desflurane, isoflurane, midazolam premedication and parental presence at emergence. Therefore anaesthetists can consider several effective strategies to reduce the risk of EA in their clinical practice. Future studies should ensure adequate analgesia in the control group, for which pain may be a contributing or confounding factor in the diagnosis of EA. Regardless of the EA scale used, it would be helpful for study authors to report the risk of EA, so that this might be included in future meta-analyses. Researchers should also consider combining effective interventions as a multi-modal approach to further reduce the risk of EA.

Intravenous versus inhalational anaesthesia for paediatric outpatient surgery

BACKGROUND

Ambulatory or outpatient anaesthesia is performed in patients who are discharged on the same day as their surgery. Perioperative complications such as postoperative nausea and vomiting (PONV), postoperative behavioural disturbances and cardiorespiratory complications should be minimized in ambulatory anaesthesia. The choice of anaesthetic agents and techniques can influence the occurrence of these complications and thus delay in discharge.

OBJECTIVES

The objective of this review was to evaluate the risk of complications (the risk of postoperative nausea and vomiting (PONV), admission or readmission to hospital, postoperative behavioural disturbances and perioperative respiratory and cardiovascular complications) and recovery times (time to discharge from recovery ward and time to discharge from hospital) comparing the use of intravenous to inhalational anaesthesia for paediatric outpatient surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 8); MEDLINE (1948 to 1 October 2013); EMBASE (1974 to 1 October 2013); Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) (1982 to 1 October 2013). We also handsearched relevant journals and searched the reference lists of the articles identified.

SELECTION CRITERIA

We included randomized controlled trials comparing paediatric outpatient surgery using intravenous versus inhalational anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. When necessary, we requested additional information and clarification of published data from the authors of individual trials.

MAIN RESULTS

We included 16 trials that involved 900 children in this review. Half of all the studies did not describe the generation of randomized sequence and most studies did not describe adequate allocation sequence concealment. The included studies showed variability in the types and combinations of drugs and the duration of anaesthesia, limiting the meta-analysis and interpretation of the results.For the induction and maintenance of anaesthesia there was a significant difference favouring intravenous anaesthesia with propofol; the incidence of PONV was 32.6% for sevoflurane and 16.1% for propofol (odds ratio (OR) 2.96; 95% confidence interval (CI) 1.35 to 6.49, four studies, 176 children, low quality evidence). The risk of postoperative behavioural disturbances also favoured intravenous anaesthesiaas the incidence was 24.7% for sevoflurane and 11.5% for propofol (OR 2.67; 95% CI 1.14 to 6.23, four studies, 176 children, very low quality evidence). There were no differences between groups in the risk of intraoperative and postoperative respiratory and cardiovascular complications (OR 0.75; 95% CI 0.27 to 2.13, three studies,130 children, very low quality evidence) and there was no difference in the time to recovery from anaesthesia and discharge from hospital. These results should be interpreted with caution due to heterogeneity between studies in the type and duration of operations, types of reported complications and the high risk of bias in almost all studies. Two studies (105 participants) compared halothane to propofol and showed heterogeneity in duration of anaesthesia and in the type of ambulatory procedure. For the risk of PONV the results of the studies were conflicting, and for the risks of intraoperative and postoperative complications there were no significant differences between the groups.For the maintenance of anaesthesia there was a significant difference favouring anaesthesia with propofol, with or without nitrous oxide (N2O), when compared to thiopentone and halothane + N2O (OR 3.23; 95% CI 1.49 to 7.02, four studies, 176 children, low quality evidence; and OR 7.44; 95% CI 2.60 to 21.26, two studies, 87 children, low quality evidence), respectively. For the time to discharge from the recovery room, there were no significant differences between groups. The studies were performed with different ambulatory surgeries and a high risk of bias.Four studies (250 participants) compared the induction of anaesthesia by the inhalational or intravenous route, with inhalational anaesthesia for maintenance, and found no significant differences between groups in all outcomes (the risk of PONV, behavioural disturbances, respiratory and cardiovascular complications and time to discharge from recovery room). Meta-analysis was not done in this comparison because of significant clinical heterogeneity.Readmission to hospital was not reported in any of the included studies. No other adverse effects were reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether intravenous anaesthesia with propofol for induction and maintenance of anaesthesia in paediatric outpatients undergoing surgery reduces the risk of postoperative nausea and vomiting and the risk of behavioural disturbances compared with inhaled anaesthesia. This evidence is of poor quality. More high-quality studies are needed to compare the different types of anaesthesia in different subsets of children undergoing ambulatory surgery.

Lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane: a meta-analysis of randomized controlled trials

BACKGROUND

Emergence agitation (EA) from general anesthesia has been reported as an adverse effect of sevoflurane in children. We describe a meta-analysis of randomized controlled trials that compared the incidence of EA between children who underwent sevoflurane anesthesia and those who underwent propofol anesthesia.

METHODS

A literature search was conducted to identify clinical trials that met our inclusion criteria. Prospective randomized trials comparing sevoflurane and propofol anesthesia in children less than 15 years of age were included in the meta-analysis. Data from each trial were combined using the random effects model to calculate pooled odds ratios (ORs) and their corresponding 95 % confidence intervals (CIs). The heterogeneity of data was assessed by Cochran's Q and I (2) tests. Sensitivity analysis was conducted for study quality, patient age, and type of surgical procedure.

RESULTS

The meta-analysis included 14 studies, in which 560 patients received sevoflurane and 548 received propofol. The pooled OR for EA was 0.25 with a 95 % CI of 0.16-0.39 (P = 0.000), which indicates that propofol anesthesia resulted in a lower incidence of EA. The heterogeneity of data was not statistically supported (P = 0.191). All sensitivity analyses strengthened the evidence for the lower incidence of EA with propofol.

CONCLUSIONS

Our meta-analysis demonstrated that EA in children is less likely to occur after propofol anesthesia compared with sevoflurane anesthesia.

Clinical and biochemical effects of propofol EDTA vs sevoflurane in healthy infants and young children

BACKGROUND

Propofol is frequently used for the induction and maintenance of anaesthesia in children aged 3 years and older. The present study compared the clinical and chemical effects of propofol containing disodium edetate (Diprivan) with that of sevoflurane in children younger than 3 years of age.

METHODS

This was an open-label, comparative, parallel-group study. Fifty-six healthy children were randomly assigned to receive either propofol (n=28; mean age 14.7 months) or sevoflurane (n=28; mean age 13.2 months) for ambulatory surgical procedures. Anaesthesia was induced with nitrous oxide (60%), oxygen and sevoflurane (8%). In the propofol group, it was followed by an intravenous infusion of propofol at a rate of 200 microg.kg(-1).min(-1). For the sevoflurane group, anaesthesia was maintained with sevoflurane (1.5-2.5%). Haemodynamic measurements, recovery time and side-effects were recorded. Ionized calcium and magnesium concentrations in blood were measured. Statistical analysis was performed using ancova and the Fisher's exact test.

RESULTS

The effects of propofol were similar to those of sevoflurane with respect to haemodynamic profile, recovery times (20 min vs 19.4 min) and side-effects (i.e. vomiting 10.7% vs 7.1%). Throughout the study, there were no significant differences between the mean ionized calcium and ionized magnesium concentrations in the two groups.

CONCLUSIONS

In children younger than 3 years of age, propofol containing ethylenediaminetetraacetic acid has a similar profile to sevoflurane with respect to haemodynamic effects, recovery times, side-effects, ionized calcium and ionized magnesium levels.

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.

Emergence agitation after sevoflurane versus propofol in pediatric patients

Sevoflurane may be associated with a high incidence of emergence agitation in preschool children. We tested the hypothesis that maintenance of anesthesia with propofol after sevoflurane induction would reduce the incidence of this excitatory behavior compared with continuing sevoflurane for maintenance. We conducted a randomized, single-blinded, two-period, cross-over study in 16 preschool age children undergoing repeated brief general anesthetics for eye examination. After sevoflurane induction, patients were randomly assigned to receive either sevoflurane or propofol anesthesia for maintenance. The alternative anesthetic was used for the maintenance of anesthesia on the second occasion. We compared the speed and quality of recovery characteristics of these anesthetics, as well as, overall parent satisfaction with anesthesia. Eight patients first received sevoflurane and the remaining eight patients first received propofol. Of the patients who received sevoflurane for the maintenance of anesthesia, 38% developed emergence agitation. In contrast, none developed emergence agitation when propofol was administered for maintenance of anesthesia. Despite emergence agitation, sevoflurane provided a shorter postanesthesia care unit stay than propofol. Parent satisfaction with anesthesia was greater with propofol than with sevoflurane.

IMPLICATIONS

In this cross-over study, we observed the incidence of emergence agitation with sevoflurane (38%) was significantly greater than with propofol (0%) in premedicated, preschool-aged children undergoing minor noninvasive surgery.

Emergence agitation after sevoflurane versus propofol in pediatric patients

Sevoflurane may be associated with a high incidence of emergence agitation in preschool children. We tested the hypothesis that maintenance of anesthesia with propofol after sevoflurane induction would reduce the incidence of this excitatory behavior compared with continuing sevoflurane for maintenance. We conducted a randomized, single-blinded, two-period, cross-over study in 16 preschool age children undergoing repeated brief general anesthetics for eye examination. After sevoflurane induction, patients were randomly assigned to receive either sevoflurane or propofol anesthesia for maintenance. The alternative anesthetic was used for the maintenance of anesthesia on the second occasion. We compared the speed and quality of recovery characteristics of these anesthetics, as well as, overall parent satisfaction with anesthesia. Eight patients first received sevoflurane and the remaining eight patients first received propofol. Of the patients who received sevoflurane for the maintenance of anesthesia, 38% developed emergence agitation. In contrast, none developed emergence agitation when propofol was administered for maintenance of anesthesia. Despite emergence agitation, sevoflurane provided a shorter postanesthesia care unit stay than propofol. Parent satisfaction with anesthesia was greater with propofol than with sevoflurane.

IMPLICATIONS

In this cross-over study, we observed the incidence of emergence agitation with sevoflurane (38%) was significantly greater than with propofol (0%) in premedicated, preschool-aged children undergoing minor noninvasive surgery.