Recovery characteristics of desflurane versus halothane for maintenance of anesthesia in pediatric ambulatory patients

Incidence of emergence agitation in children undergoing sevoflurane anesthesia compared to isoflurane anesthesia: An updated systematic review and meta-analysis

BACKGROUND

Emergence agitation is a complex syndrome of altered consciousness after emergence from anesthesia. It can result in injury to patients and staff and is associated with other postoperative complications. Sevoflurane has been associated with emergence agitation, potentially due to low tissue solubility and therefore speed of emergence. Prior meta-analyses comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics did not demonstrate a statistically significant difference. Given the publication of additional relevant studies not included in prior meta-analyses as well as improved diagnosis of emergence agitation, we aim to perform an updated, comprehensive meta-analysis comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics in children.

METHODS

We conducted an updated systematic review and meta-analysis of clinical trials comparing sevoflurane to isoflurane in children <18 years of age, reporting emergence agitation as an outcome, published before July 2023 using databases and registers. Our primary outcome was the incidence of emergence agitation. Secondary outcomes were time to extubation, awakening time, and length of stay in the postanesthetic care unit. We assessed the risk of bias using the Cochrane Risk of Bias tool version 2. We pooled the effect size for the outcomes using the fixed effects model if we had low heterogeneity, otherwise, we used a random-effects model.

RESULTS

Eight randomized controlled trials (523 children) were included in the final analysis. The incidence of emergence agitation after isoflurane was significantly lower compared to sevoflurane (risk ratio: 0.62 (95% CI: [0.46-0.83]; I2  = 40.01%, p < .001)). Time to extubation, awakening times, and postanesthetic care unit duration were not significantly different. The protective effect of isoflurane compared to sevoflurane remained significant in subgroups of patients who received premedication or intraoperative systemic analgesics (risk ratios: (0.48 [0.28-0.82]; I2  = 60.78%, p = .01), (0.52 [0.37-0.75]; I2  = 0.00%, p < .001), respectively).

CONCLUSION

The risk of emergence agitation in children after maintenance anesthesia with sevoflurane is significantly greater than with isoflurane; we did not find evidence of prolonged emergence or postanesthetic length of stay. When possible, isoflurane should be considered for maintenance anesthesia over sevoflurane in patients at high risk of emergence agitation.

Prophylaxis for paediatric emergence delirium in desflurane-based anaesthesia: a network meta-analysis

PURPOSE

The prevalence of postoperative emergence delirium in paediatric patients (pedED) following desflurane anaesthesia is considerably high at 50-80%. Although several pharmacological prophylactic strategies have been introduced to reduce the risk of pedED, conclusive evidence about the superiority of these individual regimens is lacking. The aim of the current study was to assess the potential prophylactic effect and safety of individual pharmacotherapies in the prevention of pedED following desflurane anaesthesia.

METHODS

This frequentist model network meta-analysis (NMA) of randomized controlled trials (RCTs) included peer-reviewed RCTs of either placebo-controlled or active-controlled design in paediatric patients under desflurane anaesthesia.

RESULTS

Seven studies comprising 573 participants were included. Overall, the ketamine + propofol administration [odds ratio (OR) = 0.05, 95% confidence intervals (95%CIs) 0.01-0.33], dexmedetomidine alone (OR = 0.13, 95%CIs 0.05-0.31), and propofol administration (OR = 0.30, 95%CIs 0.10-0.91) were associated with a significantly lower incidence of pedED than the placebo/control groups. In addition, only gabapentin and dexmedetomidine were associated with a significantly higher improvement in the severity of emergence delirium than the placebo/control groups. Finally, the ketamine + propofol administration was associated with the lowest incidence of pedED, whereas gabapentin was associated with the lowest severity of pedED among all of the pharmacologic interventions studied.

CONCLUSIONS

The current NMA showed that ketamine + propofol administration was associated with the lowest incidence of pedED among all of the pharmacologic interventions studied. Future large-scale trials to more fully elucidate the comparative benefits of different combination regimens are warranted.

TRIAL REGISTRATION

PROSPERO CRD42021285200.

Adjuvants for balanced anesthesia in ambulatory surgery

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.

The Effect of Intraoperative Magnesium Sulphate Infusion on Emergence Agitation after Ambulatory Ophthalmic Surgery in Children

This study investigated whether intraoperative infusion of magnesium sulphate reduces the incidence of emergence agitation (EA) in paediatric patients who undergo ambulatory ophthalmic surgery using the Paediatric Anaesthesia Emergence Delirium (PAED) scale. Ninety-two paediatric patients who were scheduled for elective ophthalmic surgery were randomly allocated to two groups: control or magnesium. In the magnesium group, patients received an initial intravenous loading dose of 30 mg/kg of 10% solution of magnesium sulphate over 10 min and then a continuous infusion of 10 mg/kg×h during the surgery. In the control group, an equal volume of 0.9% isotonic saline was administered in the same way as in the magnesium group. The PAED scale was assessed at 15-min intervals until the PAED score reached below 10 at the postanaesthetic care unit. EA was defined as a PAED score of 10 or higher. Of the 86 patients recruited, 44 and 42 were allocated to the control and magnesium groups, respectively. The incidence of EA was 77.3% in the control group and 57.1% in the magnesium group (odds ratio, 0.392; 95% confidence interval, 0.154 to 0.997; p = 0.046). The intraoperative infusion of magnesium sulphate significantly reduced the incidence of EA.

The Addition of Intravenous Propofol and Ketorolac to a Sevoflurane Anesthetic Lessens Emergence Agitation in Children Having Bilateral Myringotomy with Tympanostomy Tube Insertion: A Prospective Observational Study

The aim of this prospective observational study was to determine if children undergoing bilateral myringotomy and tympanostomy tube insertion with a sevoflurane anesthetic plus intravenous propofol and ketorolac experienced a lower incidence of emergence agitation than those receiving a sevoflurane anesthetic alone. Duration of procedure, length of stay in post-anaesthesia care and level of nursing effort required to care for patients were also assessed. In this study, 49 children younger than 13 years of age received a sevoflurane anesthetic. Fifty-one percent of these patients also received a single injection of propofol 1 mg/kg and ketorolac 0.5 mg/kg at the end of the procedure. Patients were assessed for emergence agitation using the Pediatric Anesthesia Emergence Delirium scale in the post-anaesthesia care unit. Four children receiving a sevoflurane anesthetic alone experienced emergence agitation, while no children receiving propofol and ketorolac experienced emergence agitation (p = 0.05). The length of stay until discharge from the hospital was 6.98 min longer for patients receiving propofol and ketorolac but did not reach statistical significance (p = 0.23). Nurses reported greater ease in caring for patients receiving the propofol and ketorolac injection (recovery questionnaire score 4.50 vs. 3.75, p = 0.002). In this study, adding a single injection of intravenous propofol and ketorolac to the end of a brief sevoflurane anesthetic for bilateral myringotomy with tube insertion was associated with a lower incidence of emergence agitation without significantly increasing the time to discharge from the hospital.

Emergence Delirium in Perioperative Pediatric Care: A Review of Current Evidence and New Directions

Emergence delirium (ED) is defined as psychomotor agitation and delirium that typically occurs within 45 min from emergence of anesthesia. Preoperative patient conditions such as anxiety and confusion are risk factors for the development of postoperative ED. Common signs of ED are general non-purposeful resistive movements such as kicking, pulling, flailing as well as lack of eye contact and general lack of awareness of surroundings. The use of volatile anesthetics (VA) is contributory, while the use of total intravenous anesthetic techniques (TIVA) may help to reduce the incidence of emergence delirium. Furthermore, various pharmacologic strategies and alternatively non-pharmacologic strategies have been demonstrated to further diminish its occurrence. The objective of this manuscript is to provide a comprehensive review of anesthetic considerations for pediatric ED and to provide an update on techniques that have been found to be effective in reducing the overall risk of developing postoperative ED in pediatric patients.

Effect of dexmedetomidine on emergence agitation using desflurane in pediatric cataract surgery

Background

In this study, we compared effectiveness of two doses of dexmedetomidine (0.15 μg/kg and 0.3 μg/kg) in preventing desflurane-induced emergence agitation (EA) in pediatric patients undergoing elective cataract surgery.

Methods

It is a prospective double-blinded randomized study conducted on 65 American Society of Anesthesiologists 1 children (2-10 years) who underwent elective cataract surgery at our institute. They were randomized into two equal groups, who received either dexmedetomidine 0.15 μg/kg (Group D_0.15) or dexmedetomidine 0.30 μg/kg (Group D_0.3) intravenously after induction of anesthesia. An observer blinded to groups recorded heart rate (HR), arterial blood pressure, oxygen saturation, end-tidal carbon dioxide, and respiratory rate (RR) at regular intervals and evaluated preoperative anxiety, state of agitation, and postoperative pain using validated scores.

Results

Both groups (Group D_0.15, n = 27 vs. Group D_0.3, n = 26) were demographically identical. In intraoperative period, the difference in HRs was significantly lower in Group D₀.₃ from 5 min till 15 min of the surgery (P < 0.05), but thereafter, from 20 min till end of surgery, the rates were comparable in both the groups, whereas RR and blood pressure fluctuations were comparable throughout. Postoperative pain scores and postoperative agitation score were significantly lower in Group D_0.3 than D_0.15 at all time intervals (P < 0.05).

Conclusions

In our study, 0.3 μg/kg intravenous dexmedetomidine was found to be superior to 0.15 μg/kg group in effectively reducing EA and postoperative pain, without producing adverse effects such as hypotension or bradycardia.

Comparing incidence of emergence delirium between sevoflurane and desflurane in children following routine otolaryngology procedures

BACKGROUND

Emergence delirium (ED) is a state of aggressive agitation that can occur temporarily in the process of emerging from anesthesia in children exposed to volatile or intravenous anesthetics. Emergence delirium is typically assessed using the published and validated Pediatric Emergence Delirium (PAED) Scale. Due to some variation in properties between sevoflurane and desflurane for maintenance of anesthesia after standard sevoflurane induction, we designed a prospective study to examine potential differences in emergence behavior and incidence of ED in children undergoing elective ear-nose-throat surgery.

METHODS

Forty-six children aged 12 months-7 years were randomly assigned to receive either sevoflurane (N.=23) or desflurane (N.=23) for maintenance of general anesthesia. All patients were extubated awake in the OR, and upon arrival in the PACU, PAED scores were assessed every 15 minutes until discharged. In addition to PAED scores, time to tracheal extubation, emergence behavior, pain scores, and recovery complications were recorded.

RESULTS

We found no significant difference in incidence of ED or peak PAED scores between sevoflurane and desflurane groups (12 [0-18] versus 12 [0-20]; P=0.79). There were no significant differences between desflurane and sevoflurane with respect to incidence of adverse events, such as nausea, vomiting, laryngospasm, or excessive secretions.

CONCLUSIONS

In conclusion, the use of desflurane for maintenance of anesthesia did not significantly affect the incidence or duration of ED when compared to sevoflurane. However, desflurane did not demonstrate any increase in adverse events, which may support its routine use in this patient population.

Appropriate dose of dexmedetomidine for the prevention of emergence agitation after desflurane anesthesia for tonsillectomy or adenoidectomy in children: up and down sequential allocation

Background

Dexmedetomidine can be used for the prevention of emergence agitation (EA) in children. However, an inadequate dose of dexmedetomidine can induce prolonged sedation and cardiovascular complications. The aim of this study was to evaluate the effective dose of dexmedetomidine for the prevention of EA after desflurane anesthesia for patients undergoing a tonsillectomy or adenoidectomy.

Methods

We enrolled 21 unpremedicated children, between 2 and 12 years, undergoing either a tonsillectomy or an adenoidectomy. General anesthesia was induced using sevoflurane and oxygen, and dexmedetomidine was administered before surgery. Anesthesia was maintained using desflurane resulting in a BIS range of 40–60. In the postanesthetic care unit (PACU), EA (agitation measured at level 4 or more at least once) was assessed on arrival in the PACU,15 min later, and 30 min later. The dose of dexmedetomidine for consecutive patients was determined by the response of the previous patient, using an increment or decrement of 0.1 μg/kg.

Results

The 50 % effective dose of dexmedetomidine for prevention of EA was 0.25 μg/kg (95 % confidence limits, 0.17–0.33 μg/kg), and the 95 % effective dose was 0.38 μg/kg (95 % confidence limits, 0.29–0.39 μg/kg).

Conclusions

For prevention of EA after desflurane anesthesia for 50 % and 95 % of children undergoing tonsillectomies or adenoidectomies, 0.25 μg/kg or 0.38 μg/kg of dexmedetomidine is suggested. Further study is needed to validate the suggested dose of dexmedetomidine to prevent the EA that was identified in the present study.

Trial registration

Clinical Research Information Service KCT0000126.

Emergence agitation prevention in paediatric ambulatory surgery: A comparison between intranasal Dexmedetomidine and Clonidine

Objective:

Emergence agitation (EA), a short-lived, self-limiting phenomenon, arises frequently after the use of inhalational agents and hampers the implementation of pediatric ambulatory surgery in spite of using so many drugs with variable efficacy.

Methods:

In this prospective, double-blinded, parallel group study (2008–2009), 80 children of both sex aged 3–7 years, with American Society of Anesthesiologists (ASA) physical status grade I-II, undergoing sevoflurane-based general anesthesia for elective day care surgery were randomly assigned into groups C or D. Group C received 4 μg/kg intranasal clonidine, whereas group D received 1 μg/kg intranasal dexmedetomidine, 45 min before induction of anesthesia. In postanesthesia care unit (PACU), the incidence of EA was assessed with Aonos four-point scale and the severity of EA was assessed with pediatric anesthesia emergence delirium scale upon admission (T0), after 5 min (T5), 15 min (T15), and 25 min (T25). Extubation time, emergence time, duration of PACU stay, dose and incidence of fentanyl use for pain control were noted.

Findings:

Based on comparable demographic profiles, the incidence and severity of EA were significantly lower in group D as compared to group C at T0, T5, T15, and T25. But time of regular breathing, awakening, extubation, and emergence were significantly delayed in group D than C. The number and dose of fentanyl used in group C were significantly higher than group D. PACU and hospital stay were quite comparable between groups.

Conclusion:

Intranasal dexmedetomidine 1 μg/kg was more effective than clonidine 4 μg/kg in decreasing the incidence and severity of EA, when administered 45 min before the induction of anesthesia with sevoflurane for pediatric day care surgery. Dexmedetomidine also significantly reduced fentanyl consumption in PACU.

The impact of clonidine on sedation after adenotonsillectomy: a prospective audit

AIMS

Clonidine may be used intraoperatively to decrease emergence delirium in children, but the drug's impact on postoperative sedation is poorly quantified.

METHODS

A prospective audit of children (≤15 years) undergoing (adeno) tonsillectomy or adenoidectomy over a period of 4 months was carried out. All children received sevoflurane for induction and maintenance of anesthesia. The use of clonidine as an adjunct was left to the discretion of the anesthesiologist. Postoperative sedation was assessed using the University of Michigan Sedation Scale (UMSS) at 30 min intervals until discharge. Arousal was characterized using a zero asymptote model. The impact of clonidine dose on half-time to an awake state after anesthesia was investigated using nonlinear mixed effects models. Survival analysis was used to explore the effect of clonidine dose on discharge time.

RESULTS

The mean age of children (n = 177) was 5.4 sd 3.3 years, range 0.8-15.0 years and weight was 23.8 SD 11.4 kg, range 10.0-76.4 kg. There were 73 children given clonidine 0.29-4.80 mcg·kg(-1) after induction. The half-time to emergence was 10.8 (95% CI 8.5, 13.2) min. Emergence half-time was increased to 15 min with clonidine 0.5 mcg·kg(-1), 20 min with clonidine 1.5 mcg·kg(-1), 25 min with clonidine 2 mcg·kg(-1) and 65 min with clonidine 4 mcg·kg(-1). Clonidine doses 0.5-3 mcg·kg(-1) did not affect hospital discharge time.

CONCLUSIONS

Clonidine administered intraoperatively for (adeno) tonsillectomy or adenoidectomy prolonged emergence from anesthesia. Doses of 0.5-3 mcg·kg(-1) caused greater sedation in the postanesthesia care unit but did not impact on hospital discharge times.

Low-dose dexmedetomidine reduces emergence agitation after desflurane anaesthesia in children undergoing strabismus surgery

PURPOSE

Emergence agitation (EA) is frequently observed in children undergoing general anaesthesia. This study tested whether the addition of an intra-operative low-dose infusion of dexmedetomidine to fentanyl treatment reduced the incidence of emergence delirium following desflurane anesthesia in children undergoing strabismus surgery.

MATERIALS AND METHODS

A total of 96 children (1-5 years old) undergoing strabismus surgery were enrolled. Anaesthesia was induced with propofol and maintained with desflurane. After induction, fentanyl (1 μg/kg) was administered to all children. During surgery, patients were infused with 0.2 μg/(kg·h)⁻¹ dexmedetomidine (Group FD, n=47) or normal saline (Group F, n=47). Postoperative objective pain score (OPS), Paediatric Agitation and Emergence Delirium (PAED) score, and EA score were documented every 10 minutes in the post-anaesthesia care unit.

RESULTS

There were no significant differences between the two groups in demographic characteristics and haemodynamic changes. The mean values of maximum EA, maximum PAED, and maximum OPS score were significantly lower in Group FD than in Group F at 0, 10, and 20 minutes after arrival at the post-anaesthesia care unit (p<0.001). The frequency of fentanyl rescue was lower in Group FD than in Group F (p<0.001). The incidence of severe EA was significantly lower in Group FD than in Group F (12.8% vs. 74.5%, p<0.001).

CONCLUSION

Intra-operative low-dose infusion of dexmedetomidine in addition to fentanyl reduces EA following desflurane anaesthesia in children undergoing strabismus surgeries.

Postoperative emergence delirium in pediatric patients undergoing cataract surgery--a comparison of desflurane and sevoflurane

BACKGROUND

Desflurane and sevoflurane are associated with postoperative emergence delirium (ED) in children. The study aimed to compare the use of desflurane and sevoflurane to determine the postoperative ED in children undergoing cataract surgery using the validated Pediatric Anesthesia Emergence Delirium (PAED) scale.

METHODS

In this randomized double-blinded study, 88 children of American Society of Anesthesiologists (ASA) grade I and II aged 2-6 years, anesthesia was maintained with 1-1.2 MAC concentration of desflurane or sevoflurane after induction with sevoflurane. Subtenon block was administered in all children with 0.08-0.10 ml·kg(-1) of 0.5% bupivacaine before surgical incision. Primary outcome measured was PAED scale at different time intervals between the two groups, and secondary outcome measured was preoperative anxiety scores, postoperative pain scores, emergence, incidence of delirium and adverse effects.

RESULTS

Pediatric Anesthesia Emergence Delirium (PAED) scale showed no statistical difference between sevoflurane and desflurane at different time intervals. Incidence of ED using the cutoff of >12 in PAED scale was 8 of 44 (18.18%) in sevoflurane group and 9 of 44 (20.45%) in desflurane groups (P = 1.000). Emergence from anesthesia was faster in desflurane group (P = 0.001). Correlation between the m-YPAS anxiety scale and PAED scale in either group did not find any relationship (correlation coefficient = -0.060, P = 0.579). No correlation between the Face, Legs, Activity, Cry and Consolability (FLACC) scale and Pediatric Anesthesia Emergence Delirium (PAED) scale was found in 17 patients who had ED (correlation coefficient = 0.191, P-value = 0.462). Five patients of 17 (i.e., three patients in Group S and two patients in Group D) had PAED >12 but FLACC <4.

CONCLUSION

Emergence delirium (ED) after desflurane and sevoflurane anesthesia was comparable using a validated PAED scale in pediatric cataract surgery. There was no correlation between preoperative anxiety and ED in these children; however, children with higher pain scores were more likely to have a higher ED.

Caudal block and emergence delirium in pediatric patients: Is it analgesia or sedation?

BACKGROUND

Emergence delirium (ED) although a short-lived and self-limiting phenomenon, makes a child prone to injury in the immediate postoperative period and hence is a cause of concern not only to the pediatric anesthesiologist, surgeons, and post anesthesia care unit staff but also amongst parents. Additional medication to quieten the child offsets the potential benefits of rapid emergence and delays recovery in day care settings. There is conflicting evidence of influence of analgesia and sedation following anesthesia on emergence agitation. We hypothesized that an anesthetic technique which improves analgesia and prolongs emergence time will reduce the incidence of ED. We selected ketamine as adjuvant to caudal block for this purpose.

METHODS

This randomized, double blind prospective study was performed in 150 premedicated children ASA I, II, aged 2 to 8 years who were randomly assigned to either group B (caudal with bupivacaine), BK (bupivacaine and ketamine), or NC (no caudal), soon after LMA placement. Recovery characteristics and complications were recorded.

RESULTS

Emergence time, duration of pain relief, and Pediatric Anesthesia Emergence Delirium (PAED) scores were significantly higher in the NC group (P<0.05). Duration of analgesia and emergence time were significantly more in group BK than groups B and NC. However, the discharge readiness was comparable between all groups. No patient in BK group required to be given any medication to treat ED.

CONCLUSION

Emergence time as well as duration of analgesia have significant influence on incidence of emergence delirium. Ketamine, as caudal adjuvant is a promising agent to protect against ED in children, following sevoflurane anesthesia.

The effect of ketamine on the separation anxiety and emergence agitation in children undergoing brief ophthalmic surgery under desflurane general anesthesia

Background

Emergence agitation (EA) frequently occurs after desflurane anesthesia in children. Ketamine, because of its sedative and analgesic properties, might be useful for the management of separation anxiety and EA. We investigated the preventive effect of ketamine on separation anxiety and EA after desflurane anesthesia in children for brief ophthalmic surgery.

Methods

Sixty children, ranging in age from 2-8 years old, undergoing brief ophthalmic surgery were randomly allocated to one of the 3 groups: group C received normal saline, group K1.0 received ketamine 1.0 mg/kg intravenously before entering the operating room, or group K0.5 received ketamine 0.5 mg/kg 10 min before the end of the surgery. Before induction, the separation anxiety score was evaluated. Extubation time, post-anesthesia care unit stay time, postoperative nausea and vomiting, emergence agitation, and pain were assessed.

Results

The group K1.0 had a lower separation anxiety score compared with groups K0.5 and C. Extubation time in group K0.5 was significantly prolonged compared with groups K1.0 and C. The incidence of EA and the modified Children's Hospital of Eastern Ontario Pain Scale were significantly lower in group K1.0 and group K0.5 compared to group C, but there was no significant difference between groups K1.0 and K0.5.

Conclusions

In children undergoing brief ophthalmic surgery with desflurane anesthesia, ketamine 1.0 mg/kg administered before entering the operating room reduced separation anxiety, postoperative pain, and incidence of EA without delay in recovery.

Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge

BACKGROUND

Postoperative residual curarization (PORC) [train-of-four ratio (T4/T1) <0.9] is associated with increased morbidity and may delay postoperative recovery room (PACU) discharge. We tested the hypothesis that postoperative T4/T1 <0.9 increases PACU length of stay.

METHODS

At admission to the PACU, neuromuscular transmission was assessed by acceleromyography (stimulation current: 30 mA) in 246 consecutive patients. The potential consequences of PORC-induced increases in PACU length of stay on PACU throughput were estimated by application of a validated queuing model taking into account the rate of PACU admissions and mean length of stay in the joint system of the PACU plus patients recovering in operation theatre waiting for PACU beds.

RESULTS

PACU length of stay was significantly longer in patients with T4/T1 <0.9 (323 min), compared with patients with adequate recovery of neuromuscular transmission (243 min). Age (P=0.021) and diagnosis of T4/T1 <0.9 (P=0.027), but not the type of neuromuscular blocking agent, were independently associated with PACU length of stay. The incidence of T4/T1 <0.9 was higher in patients receiving vecuronium. Delayed discharge significantly increases the chances of patients having to wait to enter the PACU. The presence of PORC is estimated to be associated with significant delays in recovery room admission.

CONCLUSIONS

PORC is associated with a delayed PACU discharge. The magnitude of the effect is clinically significant. In our system, PORC increases the chances of patients having to wait to enter the PACU.

The effect of ketamine on the incidence of emergence agitation in children undergoing tonsillectomy and adenoidectomy under sevoflurane general anesthesia

Background

The rapid emergence and recovery from general anesthesia afforded by sevoflurane is associated with a high incidence of emergence agitation in children. Small doses of ketamine reduce the incidence of emergence agitation. This study compared the effects of ketamine 0.25 mg/kg and 0.5 mg/kg on emergence agitation and postoperative pain.

Methods

The effects of added intravenous ketamine were evaluated in 93 children, ASA I-II, 2-14 years old, undergoing an adenotonsillectomy. The patients were allocated randomly to one of three groups receiving saline (group C), ketamine 0.25 mg/kg (group K0.25) or ketamine 0.5 mg/kg (group K0.5). The children in each group were administered the study drugs 10 minutes before the end of surgery. The recovery characteristics, including the time to extubation, delivery time from the PACU, postoperative nausea and vomiting, agitation and pain were assessed.

Results

There were no significant differences in the extubation time, delivery time and postoperative nausea and vomiting between the three groups. There were significant differences in modified CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) between the three groups. The incidence of emergence agitation was low in the K0.25 and K0.5 groups compared to the control group. However, there was no significant difference between the K0.25 and K0.5 groups.

Conclusions

There was no significant difference in the incidence of emergence agitation between K0.25 and K0.5 groups. However, K0.5 group showed a lower pain score than K0.25 group.

Anesthesia induction, emergence, and postoperative behaviors in children with attention-deficit/hyperactivity disorders

BACKGROUND/AIM

Given the increasing prevalence of attention-deficit and attention-deficit hyperactivity disorders (ADHD), anesthesiologists are now presented with a greater number of children who are diagnosed with these conditions. This prospective, observational study was designed to compare anesthesia induction, emergence, and postoperative behaviors in children with and without ADHD.

METHODS/MATERIALS

The sample included 268 children, 4-17 years of age undergoing elective surgery with a confirmed diagnosis of ADHD. A cohort of children without ADHD, matched for age, gender, and procedure served as controls. Preoperative cooperation, induction, and emergence behaviors were measured using established scales. Postoperative maladaptive behaviors were measured using a modified Post-Hospital Behavioral Questionnaire that was administered via telephone 1 week after surgery.

RESULTS

Children with ADHD were significantly less cooperative at induction of anesthesia compared with controls (20.9% vs 10.6% respectively, P = 0.001). Although some control children exhibited an increase in maladaptive behaviors postoperatively, these behaviors were significantly greater among children with ADHD. In particular, relative to their normal behaviors, children with ADHD had greater difficulties in concentration and decision-making; were more disobedient, impulsive, fidgety, had poor appetite; were difficult to talk to; and exhibited an increase in temper tantrums following surgery.

CONCLUSIONS

This is the first prospective study to our knowledge that has examined the perioperative and postoperative behaviors of children with ADHD compared to those without this disorder. These results are important in alerting anesthesiologists, parents, and teachers to the potential for difficulties during induction of anesthesia and postoperative behavioral problems at home and in school, respectively.

Evaluation of emergence delirium in Asian children using the Pediatric Anesthesia Emergence Delirium Scale

BACKGROUND

Emergence delirium (ED) is a common problem in children recovering from general anesthesia. ED causes disruption in the postanesthetic care unit, making nursing and monitoring more difficult, and is potentially dangerous to the child. The greatest hindrance to understanding ED was the lack of a standardized tool to assess it. The Pediatric Anesthesia Emergence Delirium (PAED) Scale was recently described to measure the degree of ED in children. In this prospective observational study, we sought to evaluate the incidence of ED by grading emergence behavior using the PAED Score in healthy Asian children undergoing outpatient surgery.

METHODS

Three hundred sixteen children aged 2-12 years undergoing general anesthesia for elective outpatient surgery were included. No premedication was administered. Induction behavior was graded using the induction compliance checklist, and the presence of any excitation on induction documented. Emergence behavior was recorded using the PAED Scale, and the children were separately assessed for clinical agitation.

RESULTS

One hundred and thirty-six children (43%) had PAED Scores >0 and 33 (10.4%) had PAED Scores of >or=10. Only 28 children (8.9%) had clinical agitation consistent with ED, the rest were agitated for other reasons. A score of >or=10 on the PAED Scale was the best discriminator between presence and absence of clinical agitation. The area under the receiver operating characteristic curve for PAED Score of >or=10 was 0.98, with a true-positive rate (sensitivity) of 0.85 and a false-positive rate (1-specificity) of 0.041. Four factors were found to be predictive of ED. These include young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening.

CONCLUSIONS

The incidence of ED is approximately 10% in our population of healthy, unpremedicated Asian children undergoing day surgery. Young age, poor compliance at induction, lack of intraoperative fentanyl use and rapid time to awakening were predictive risk factors for ED in our population. A PAED Score of >or=10 was correlated with clinically significant ED and appeared to be the ideal cutoff score for ED.

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.

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.

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.

Emergence Delirium in Children: Many Questions, Few Answers

The introduction of a new generation of inhaled anesthetics into pediatric clinical practice has been associated with a greater incidence of ED, a short-lived, but troublesome clinical phenomenon of uncertain etiology. A variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a potential role in the development of such an event. Restless behavior upon emergence causes not only discomfort to the child, but also makes the caregivers and parents feel unhappy with the quality of recovery from anesthesia. Although the severity of agitation varies, it often requires additional nursing care, as well as treatment with analgesics or sedatives, which may delay discharge from hospital. To reduce the incidence of this adverse event, it is advisable to identify children at risk and take preventive measures, such as reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. More clinical trials are needed to elucidate the cause as well as provide effective treatment.

Prospective comparison of sevoflurane and desflurane in formerly premature infants undergoing inguinal herniotomy

BACKGROUND

Formerly premature infants having inguinal herniotomy have been at a high risk of postoperative apnoea, newer less soluble anaesthetic agents may reduce this risk.

METHODS

Thirty infants, under 37 weeks gestation and under 47 weeks post-conceptional age, undergoing inguinal herniotomy had an inhalational induction with sevoflurane and were randomly allocated to sevoflurane (group S) or desflurane (group D) for maintenance. All infants received i.v. atracurium 0.5 mg kg(-1), rectal acetaminophen 20 mg kg(-1) and caudal bupivacaine 0.25% 1 ml kg(-1). Infants were monitored for apnoeas (using nasal thermistry and impedance), haemoglobin oxygen desaturations and bradycardias for 12 h before and after operation with an Alice 4 polysomnograph. Emergence timings were recorded.

RESULTS

There was no difference between pre- and postoperative incidence of apnoeas in either group, and no group difference between desflurane and sevoflurane in terms of pre- and postoperative ventilatory events or in the number of apnoeas in the postoperative period (nine patients in group D and five patients in group S had apnoeas). Median times to first movement, tracheal extubation, eye opening and first cry were all faster with group D (group D: 3.0, 10.0, 9.0 and 11.0 min and group S: 7.0, 15.1, 13.5 and 16.1 min, respectively). No infant had problems with airway irritation on emergence and no infant required airway intervention for apnoea.

CONCLUSIONS

Infants wake faster from general anaesthesia when maintained with desflurane as compared with sevoflurane, but no difference in postoperative respiratory events was demonstrated between the groups.

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.

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.

The effects of low-dose fentanyl on emergence agitation and quality of life in patients with moderate developmental disabilities

STUDY OBJECTIVE

To analyze whether emergence agitation could be reduced by using a low dosage of fentanyl without causing an increase in postoperative adverse effects and/or affecting the patient's quality of life after discharge.

DESIGN

Randomized, controlled crossover trial.

SETTING

University medical center.

PATIENTS

One hundred ten ASA physical status I and II ambulatory patients with moderate developmental disabilities who received anesthesia for dental care.

INTERVENTIONS

During their first visit, patients were randomly treated either with a placebo or a 1- to 1.5-microg/kg dose of fentanyl before inserting a reinforced laryngeal mask airway and treated with the remaining method during their second visit 6 to 12 months later.

MEASUREMENTS

Measured variables included anesthetic and emergence period, the occurrence of emergence agitation, and postanesthetic adverse effects such as nausea and vomiting. After discharge, the patient's quality of life was evaluated based on disturbances in daily activity, eating habit, and sleeping behavior. Results were analyzed by Student t test and McNemar test (P < 0.05).

MAIN RESULTS

Between the two treatments, there was a significant difference in the frequency of emergence agitation (P = 0.04) but no postoperative adverse effects such as postoperative nausea and vomiting. We also found no significant disturbances in the patient's quality of life according to daily activity, eating habits, or sleeping behavior.

CONCLUSION

Emergence agitation may be reduced by using 1 to 1.5 microg/kg of fentanyl during induction while maintaining anesthesia by sevoflurane in patients with moderate developmental disabilities undergoing dental care, without causing an increase in postoperative adverse effects and affecting the patient's life quality after discharge.

Nurses' diagnoses and treatment decisions regarding care of the agitated child

Postoperative agitation has many potential etiologies and remains a significant clinical issue in the pediatric PACU setting. Caring for the agitated child requires a thorough assessment and calls for targeted interventions. This observational study evaluated nurses' diagnoses and treatment decisions regarding care of the agitated child. Nurses were observed during their care of 194 agitated children over a 3-month period. Pain and anxiety were the most commonly identified sources of agitation in the pediatric PACU setting (27% and 25% of cases, respectively), and nurses' targeted, primary interventions for these problems were fairly effective (48% and 67% effective, respectively). Anesthesia-induced agitation was less often identified as the etiology (11%), and primary interventions were more varied and less effective (38%). Physiologic abnormalities were identified as the source for agitation in only 3 cases, but went unrecognized for an extended period in 2 children. Results of this study underscore the complexity of assessment and treatment decisions when caring for agitated children. A decision algorithm based on this study is described as a potential aid toward differentiation of agitation and appropriate intervention.

Paediatric anaesthesia and inhalation agents

Inhalation agents are amongst the mainstays of paediatric anaesthesia, as children are often induced by mask before venous access is obtained. Children do not like needles and obtaining venous access in an awake and moving child can be very demanding. Safety aspects are of particular importance in paediatric anaesthesia. Therefore, the possibility of monitoring end-tidal concentrations facilitates correct dosing in all patients, from the preterm infant weighing less than 1000 g to the adult-sized adolescent. For induction, sevoflurane has nearly universally replaced halothane, leading to increased cardiovascular safety. The main disadvantages of inhalation agents, especially sevoflurane and desflurane, are delirious behaviour and agitated states during emergence. In addition, there remains uncertainty regarding the relevance of the cerebral stimulating pattern of some of these agents. Inhalation anaesthesia has a long tradition, whereas the experience with propofol is comparatively small. The incidence and clinical relevance of the propofol infusion syndrome during clinical anaesthesia are still unknown. Inhalation anaesthesia is still considered to be the gold standard by the overwhelming majority of paediatric anaesthetists world-wide, however, intravenous techniques can be an attractive alternative in specific clinical situations.

Ondansetron Oral Disintegrating Tablets: Acceptability and Efficacy in Children Undergoing Adenotonsillectomy

Postoperative nausea and vomiting (PONV), a major complication in children, is responsive to IV and oral ondansetron. Because these routes are not always available, we studied the acceptability and efficacy of ondansetron oral disintegrating tablets (ODT). In this double-blind, randomized, placebo-controlled study, 62 patients undergoing adenotonsillectomy, aged 5 to 11 years, preoperatively received ODT (4 mg) or placebo. Patients assessed the medication for taste and sensation. Anesthesia was induced with sevoflurane, maintained with desflurane, and supplemented with fentanyl 2.5 microg/kg and dexamethasone 0.5 mg/kg (maximum dose, 12 mg). An observer blinded to treatment evaluated patients for pain, agitation, and PONV. Postoperative treatment consisted of fentanyl 1 microg/kg for pain and agitation and metoclopramide 0.15 mg/kg (maximum dose, 10 mg) for PONV. There were no significant differences between study groups with regard to age, weight, recovery time, agitation, or pain. Approximately 90% of the subjects found the ODT to taste good. No subject rejected the study medication, but the ondansetron-containing tablets were found to be less palatable than the placebo. The incidence of vomiting was significantly less in the ondansetron-medicated group.

[Anesthetic management of pediatric cleft lip and cleft palate repair]

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.

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.

Efficacy of tramadol versus meperidine for pain relief and safe recovery after adenotonsillectomy

BACKGROUND AND OBJECTIVE

Adequate relief of pain after tonsillectomy is a common problem. We compared meperidine and tramadol when given at induction of anaesthesia with respect to their effects on postoperative pain relief and emergence characteristics after adenotonsillectomy in children.

METHODS

Fifty children aged 4-7 yr undergoing tonsillectomy were randomly assigned to receive either tramadol 1 mg kg(-1) (n = 25) or meperidine 1 mg kg(-1) (n = 25) before commencement of the surgical procedure. Anaesthesia was induced with propofol (with cis-atracurium for muscle relaxation) and maintained with sevoflurane in oxygen and nitrous oxide. Postoperative pain was scored by a blinded observer using a facial pain scale in the recovery room at 0 (at arrival of the patient in the postoperative care unit) and at 10, 20 and 45 min thereafter. Agitation scores were also assessed by the same observer at 0 min. Heart rate and mean arterial pressure were recorded at regular intervals. The time to recovery to spontaneous respiration and the incidence of postoperative nausea and vomiting were noted.

RESULTS

Facial pain scale scores were increased in the tramadol group at 0, 10 and 20 min (P < 0.05). No difference was observed in scores at the 45th min postoperation. Agitation scores were higher in the tramadol group than in the meperidine group. No statistical difference was found between the two groups. Heart rates and mean arterial pressures were similar in both groups. The time to recovery to spontaneous respiration was delayed with meperidine compared with tramadol (P < 0.05). The incidence of nausea and vomiting was not statistically different between groups.

CONCLUSIONS

Meperidine was more effective for pain relief and provides better emergence characteristics than tramadol after tonsillectomy in children.

Assessment of risk factors for emergence distress and postoperative behavioural changes in children following general anaesthesia

BACKGROUND

Emergence distress commonly occurs in children recovering from the immediate effects of general anaesthesia. This study was performed to (1) examine whether parental presence in the operating room during emergence from anaesthesia reduces the incidence or severity of emergence distress behaviour, and (2) assess psychosocial risk factors, including child temperament and sleep behaviour, for development of emergence distress.

METHODS

A randomized and controlled trial of parental presence at emergence was conducted in 100 ASA class I and II children having general anaesthesia for inguinal or penile surgery. Children in the study group had a parent present at induction and emergence of anaesthesia, while children in the control group had a parent present only at induction. Emergence and postanaesthesia care unit (PACU) behaviour was monitored using both the Operating Room Behaviour Rating Scale (ORBRS) and a 7-point Likert type cooperation scale.

RESULTS

One-way anovas showed no significant differences between the control group and the study group on emergence distress behaviour. The frequency of negative postoperative behavioural changes at 1 and 4 weeks postsurgery was low in both groups. Children described as clingy/dependent (chi2 = 5.57, P < 0.06) and children with frequent temper tantrums (chi2 = 7.44, P < 0.02) were more likely to have emergence distress behaviour.

CONCLUSIONS

Parental presence during emergence from anesthesia did not decrease the incidence or severity of emergence distress behaviour in children. Young children and children with a history of temper tantrums or separation anxiety may be more likely to develop such behaviour.

The Effect of Caudal Analgesia on Emergence Agitation in Children After Sevoflurane Versus Halothane Anesthesia

Sevoflurane anesthesia in young children has been associated with an increased incidence of emergence agitation compared with halothane. Postoperative pain may be an etiologic factor. We designed a study to compare the incidence of emergence agitation after halothane and sevoflurane anesthesia in children whose pain was managed with caudal analgesia. Eighty children undergoing inguinal hernia repair between the ages of 12 mo and 6 yr were randomly assigned to receive either halothane or sevoflurane anesthesia. Baseline preoperative anxiety was assessed with the Yale Preoperative Anxiety Scale. The children were sedated with oral midazolam, underwent a mask induction, and had a caudal block placed for postoperative analgesia. After surgery, the children's behavior was assessed with a four-point agitation scale. At 5 min after arrival in the postanesthesia care unit (PACU), sevoflurane was associated with a greater incidence of emergence agitation than halothane (26% vs 6%; P < 0.05), but not during the remainder of the PACU stay. Higher levels of preoperative anxiety were associated with difficult mask induction, agitation on admission to the PACU, and more severe agitation episodes. Emergence agitation appears to be an early and transient phenomenon after sevoflurane anesthesia in children with effective postoperative analgesia.

IMPLICATIONS

Effective postoperative analgesia may reduce the incidence of emergence agitation reported with sevoflurane anesthesia. The Yale Preoperative Anxiety Scale appears to be helpful in identifying young children who are at risk for developing emergence agitation.

[Total intravenous anesthesia. On the way to standard practice in pediatrics]

Since venous cannulation in children has become easier and extensive experience has been gained with total intravenous anaesthesia (TIVA) in adults, the interest in TIVA for children has recently increased. An intensified sensitivity of the operating room atmosphere to contamination with volatile anaesthetic agents is another important reason to choose intravenous techniques for paediatric anaesthesia. One of the most interesting agents for TIVA in paediatric anaesthesia is propofol. The pharmacokinetic and pharmacodynamic data for modern intravenous drugs is poor. Because the interpatient variability is relatively large, pharmacokinetic data can only provide guidelines for the dosage of propofol. Propofol has a rapid and smooth onset of action and is as easy to titrate in children as in adults. Propofol can be excellently controlled. Severe haemodynamic side-effects are missing in healthy children and plasma is cleared rapidly of propofol by redistribution and metabolism. There is no evidence of significant accumulation, not even after prolonged infusion times. Because propofol has no analgetic properties it must be combined with analgetics or a regional block for all painful procedures. The combination with the ultra-short acting remifentanil is a major advantage, but requires effective analgetic concepts for painful procedures. In comparison the combination of propofol with long acting opioids abolishes some of the favourable properties of propofol. Further studies of the kinetics and dynamics of propofol and other intravenous agents are needed in paediatrics which should focus on age, maturity and severity of illness. The whole importance of the propofol-infusion syndrome has to be cleared up urgently. TIVA has an important significance in paediatric anaesthesia for diagnostic and therapeutic procedures, especially where these have to be repeated. In day-case anaesthesia TIVA has advantages for all short procedures and for ENT and ophthalmic surgery: even after prolonged infusion children have an short recovery time. There is no evidence of agitation or other behavioural disorders after TIVA with propofol in paediatric anaesthesia. Propofol has anti-emetic properties. TIVA with propofol can be combined with regional anaesthesia advantageously to provide long-lasting analgesia after surgery. TIVA with propofol has been used successfully for sedation of spontaneously breathing children for MRI and CT and other procedures with open airways like bronchoscopy or endoscopy. Propofol facilitates endotracheal intubation without the use of muscle relaxants. Of course, in malignant hyperthermia TIVA will continue to be the technique of choice. Nothing is known about awareness under TIVA in paediatric patients. TIVA must be considered by comparison with the volatile agents. The use of ultra-short acting agents may cause problems such as awareness, vagal response, involuntary movements and in some cases slow recovery after prolonged infusion of propofol. But it is not known exactly how often this happens during paediatric anaesthesia. With TIVA an effective postoperative analgesia must be provided. Newer administration techniques such as the target-controlled infusions or closed-loop control systems are under development and will help to minimise the potential risk of overdosage with TIVA in paediatrics. At the present TIVA is an interesting and practicable alternative to volatile anaesthesia for pre-school and school children. TIVA with propofol in infants younger than 1 year old requires extensive experience with TIVA in older children and with the handling of this special age group and should be undertaken with maximum precautionary measures.

Assessing behaviour in children emerging from anaesthesia: can we apply psychiatric diagnostic techniques?

BACKGROUND

No standardized instrument exists for the systematic analysis of emergence behaviour in children after anaesthesia. Our purpose was to evaluate children's behaviour prior to anaesthetic induction and immediately upon emergence to develop an assessment tool using psychiatric terminology and techniques.

METHODS

This prospective study evaluated 25 children from 2 to 9 years of age for preanaesthetic psychosocial factors that might affect behaviour. Children's behaviour was observed from admission to the surgical unit through the induction of anaesthesia. All children received a standardized premedication and induction of anaesthesia. The maintenance anaesthetic was randomized to intravenous remifentanil or inhaled isoflurane. All children underwent repair of strabismus. We assessed the behaviour of children for 30 min upon emergence from anaesthesia for symptoms of pain, distress and delirium using an assessment tool we developed guided by the principles of psychiatry as described in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

RESULTS

Using our assessment tool, 44% of children demonstrated altered behaviour on emergence; 20% demonstrated complex symptoms with characteristics of delirium. Children anaesthetized with isoflurane had significantly higher postanaesthesia behaviour assessment scores than those anaesthetized with remifentanil (P = 0.04). Age was a significant variable; children <62 months were more prone to altered behaviour than those >62 months (P = 0.02). Scores did not correlate with preanaesthetic risk factors including preexisting psychological or social variables or observed preanaesthetic distress. There was no delay in hospital discharge in children assessed as having altered behaviour.

CONCLUSIONS

This exploratory study suggests that postanaesthetic behaviour abnormalities with characteristics of distress or delirium can be categorized using known DSM-IV terminology; in our cohort this behaviour was dependent on age and anaesthetic technique.

Cerebral blood flow velocity in children anaesthetized with desflurane

BACKGROUND

Desflurane allows for rapid emergence and changes in depth of anaesthesia which makes it especially suitable for neuroanaesthesia. This study was designed to determine the effects of different desflurane concentrations on cerebral blood flow velocity (CBFV) in healthy children.

METHODS

Twenty children, aged 1-7 years undergoing urological surgery were studied. Anaesthesia was induced with sevoflurane in oxygen. After tracheal intubation, sevoflurane was discontinued and ventilation with desflurane in air/oxygen was initiated and normoventilation maintained. A caudal block was performed. The patients were randomized to receive three different desflurane concentrations (0.5, 1.0 and 1.5 MAC). Fifteen minutes were allowed to reach steady-state at which time CBFV was measured by transcranial Doppler sonography. Mean arterial pressure (MAP) and heart rate (HR) were simultaneously recorded at 1-min intervals.

RESULTS

Cerebral blood flow velocity increased from 0.5 to 1.0 MAC (P < 0.05), but not from 1.0 to 1.5 MAC. HR increased from 0.5 to 1.0 (P < 0.001) and from 1.0 to 1.5 MAC (P < 0.001), whereas the MAP decreased only from 0.5 to 1.0 MAC (P < 0.001).

CONCLUSIONS

Desflurane in concentrations of 1.0 and 1.5 MAC in children increases CBFV significantly when compared with 0.5 MAC. These changes were associated with a significant increase in HR and decrease in MAP.

A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit

Emergence agitation (EA) is a postanesthetic problem that interferes with a child's recovery and presents a challenge in terms of assessment and management. In this prospective cohort study, we sought to determine the incidence of EA, evaluate factors associated with and predictive of EA, and describe associated outcomes in healthy children. Children aged 3-7 yr who were undergoing general anesthesia for elective outpatient procedures were included. All perioperative care was documented, and postoperative behaviors in the postanesthesia care unit were recorded. Parents completed the Behavioral Style Questionnaire for 3- to 7-yr-olds. Five-hundred-twenty-one children were studied, of whom 96 (18%) had EA. Agitation lasted up to 45 min in some cases (range, 3-45 min; mean, 14 +/- 11 min), required pharmacologic intervention in 52% of children, and was associated with a prolonged postanesthesia care unit stay (117 +/- 66 min versus 101 +/- 61 min for nonagitated children; P = 0.02). Ten factors were found to be associated with EA, including age, previous surgery, adaptability, ophthalmology and otorhinolaryngology procedures, sevoflurane, isoflurane, sevoflurane/isoflurane, analgesics, and time to awakening. Of these, otorhinolaryngology procedures, time to awakening, and isoflurane were shown to be independent risk factors.

IMPLICATIONS

Children may become agitated after general anesthesia. This study describes several factors that may increase the risk for agitation. These data are important in planning anesthesia care for young children.