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Abdallah BM, Elshoeibi AM, ElTantawi N, Arif M, Hourani RF, Akomolafe AF, Hamwi MN, Mahmood FR, Saracoglu KT, Saracoglu A, Chivese T. Comparison of postoperative pain in children after maintenance anaesthesia with propofol or sevoflurane: a systematic review and meta-analysis. Br J Anaesth 2024:S0007-0912(24)00153-3. [PMID: 38670899 DOI: 10.1016/j.bja.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/04/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Mariah Arif
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Razan F Hourani
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | | | - Mahmoud N Hamwi
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | | | - Kemal T Saracoglu
- College of Medicine, QU Health, Qatar University, Doha, Qatar; Department of Anaesthesiology, ICU, and Perioperative Medicine, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ayten Saracoglu
- College of Medicine, QU Health, Qatar University, Doha, Qatar; Department of Anaesthesiology, ICU, and Perioperative Medicine, Aisha Bint Hamad Al-Attiyah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Tawanda Chivese
- College of Medicine, QU Health, Qatar University, Doha, Qatar.
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Li MY, Fei YD, Zhang XX, Chen TW, Li J, Sun XL, Wang ZY. Application of propofol-remifentanil intravenous general anesthesia combined with regional block in pediatric ophthalmic surgery. BMC Anesthesiol 2024; 24:147. [PMID: 38632505 PMCID: PMC11022467 DOI: 10.1186/s12871-024-02531-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE The aim of this study is to observe the anesthetic effect and safety of intravenous anesthesia without muscle relaxant with propofol-remifentanil combined with regional block under laryngeal mask airway in pediatric ophthalmologic surgery. METHODS A total of 90 undergoing ophthalmic surgery were anesthetized with general anesthesia using the laryngeal mask airway without muscle relaxant. They were randomly divided into two groups: 45 children who received propofol-remifentanil intravenous anesthesia combined with regional block (LG group), and 45 children who received total intravenous anesthesia (G group). The peri-operative circulatory indicators, awakening time after general anesthesia, postoperative analgesic effect and the incidence of anesthesia-related adverse events were respectively compared between the two groups. RESULTS All the children successfully underwent the surgical procedure. The awakening time after general anesthesia and removal time of laryngeal mask were significantly shorter in the LG group than in the G group (P < 0.05). There was no statistically significant difference in the heart rates in the perioperative period between the two groups (P > 0.05). There was no statistically significant difference in the incidence of intraoperative physical response, respiratory depression, postoperative nausea and vomiting (PONV) and emergence agitation (EA) between the two groups (P > 0.05). The pain score at the postoperative hour 2 was lower in the LG group than in the G group (P < 0.05). CONCLUSION Propofol-remifentanil intravenous anesthesia combined with long-acting local anesthetic regional block anesthesia, combined with laryngeal mask ventilation technology without muscle relaxants, can be safely used in pediatric eye surgery to achieve rapid and smooth recovery from general anesthesia and better postoperative analgesia. This anesthesia scheme can improve the comfort and safety of children in perioperative period, and has a certain clinical popularization value.
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Affiliation(s)
- Ming-Ying Li
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 5 Jingyuan Street, Beijing, 100043, China
| | - Yu-Da Fei
- Department of Anesthesiology, Eye Hospital China Academy of Chinese Medical Sciences, Beijing, 100040, China
| | - Xiao-Xia Zhang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 5 Jingyuan Street, Beijing, 100043, China.
| | - Tian-Wen Chen
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 5 Jingyuan Street, Beijing, 100043, China
| | - Jie Li
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 5 Jingyuan Street, Beijing, 100043, China
| | - Xiao-Li Sun
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 5 Jingyuan Street, Beijing, 100043, China
| | - Zhen-Yuan Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 5 Jingyuan Street, Beijing, 100043, China
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Jones Oguh S, Iyer RS, Yuan I, Missett R, Daly Guris RJ, Johnson G, Babus LW, Massa CB, McClung-Pasqualino H, Garcia-Marcinkiewicz AG, Sequera-Ramos L, Kurth CD. Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project. Paediatr Anaesth 2024; 34:160-166. [PMID: 37962837 DOI: 10.1111/pan.14791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/12/2023] [Accepted: 10/22/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia. AIMS We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations. METHODS The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart. RESULTS After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001). CONCLUSION Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.
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Affiliation(s)
- Sheri Jones Oguh
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Rajeev S Iyer
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ian Yuan
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Richard Missett
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Rodrigo J Daly Guris
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Gregory Johnson
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Lenard W Babus
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Christopher B Massa
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Heather McClung-Pasqualino
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Annery G Garcia-Marcinkiewicz
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Luis Sequera-Ramos
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - C Dean Kurth
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Suzuki Y, Miyasaka KW, Hayashi K, Takahashi O, Nagasaka Y. Protocol for a randomized controlled trial to reduce pediatric anesthesia emergence delirium by titration of sevoflurane anesthesia using brain function monitoring. Trials 2023; 24:734. [PMID: 37974297 PMCID: PMC10655373 DOI: 10.1186/s13063-023-07785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Emergence agitation or emergence delirium is a common complication of unknown etiology in pediatric anesthesia. Pediatric anesthesia emergence delirium (PAED) has been reported most commonly in younger children and may occur in about 30% of children up to 5-6 years old. Exposure to anesthetic agents may contribute to PAED, and we hypothesized that a management strategy to minimize exposure to volatile anesthetics may reduce PAED. Electroencephalography (EEG) signatures captured and displayed by brain function monitors during anesthesia change with concentration of sevoflurane and level of unconsciousness, and these EEG signatures may be used to inform titration of anesthetics. METHODS A single-center, parallel-group, two-arm, superiority trial with a 1:1 allocation ratio will be performed to compare the incidence of PAED following standard sevoflurane anesthesia (maintained at 1.0MAC) and EEG-guided anesthesia (minimum concentration to sustain surgical anesthesia as determined by monitoring of EEG signatures). Participants between 1 and 6 years of age undergoing surgical procedures involving minimal postoperative pain will be randomly assigned to receive standard (n = 90) or EEG-guided (n = 90) anesthesia. PAED score will be assessed by a blinded observer in the PACU on arrival and after 5, 10, 15, and 30 min. DISCUSSION Anesthesia management with proactive use of brain function monitoring is expected to reduce exposure to sevoflurane without compromising surgical anesthesia. We expect this reduced exposure should help prevent PAED. Routinely administering what may be considered standard levels of anesthetic such as 1.0 MAC sevoflurane may be excessive and potentially associated with unfavorable sequelae such as PAED. TRIAL REGISTRATION Japan Registry of Clinical Trials (jRCT) jRCTs032210248. Prospectively registered on 17 August 2021.
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Affiliation(s)
- Yasuyuki Suzuki
- National Center for Child Health and Development, Tokyo, Japan
- Tokyo Women's Medical University, Tokyo, Japan
| | - Kiyoyuki W Miyasaka
- National Center for Child Health and Development, Tokyo, Japan.
- Tokyo Women's Medical University, Tokyo, Japan.
- St. Luke's International University, Tokyo, Japan.
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Bromfalk Å, Hultin M, Myrberg T, Engström Å, Walldén J. Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine. Paediatr Anaesth 2023; 33:962-972. [PMID: 37528645 DOI: 10.1111/pan.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2-6 years. METHODS In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured. RESULTS After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups. CONCLUSIONS No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2 -agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.
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Affiliation(s)
- Åsa Bromfalk
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sunderbyn), Umeå University, Umeå, Sweden
| | - Åsa Engström
- Division of Nursing and Medical Technology, Department of Health, Education and Technology, Lulea University of Technology, Luleå, Sweden
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine (Sundsvall), Umeå University, Umeå, Sweden
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Xu Q, Zhang J, Gao Z, Li S, Li G. Analysis of the relationship between EEG burst suppression and poor prognosis in children under general anaesthesia: study protocol for a prospective, observational, single-centre study. Trials 2023; 24:481. [PMID: 37501064 PMCID: PMC10375778 DOI: 10.1186/s13063-023-07478-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Emergence delirium (ED) in children refers to the immediate postoperative period when children experience decreased perception of their surroundings, accompanied by disorientation and altered perception. Burst suppression (BS) is recognised as periods longer than 0.50 s during which the EEG does not exceed approximately + 5.0 mV, which is an electroencephalographic state associated with profound inactivation of the brain. Our primary objective was to determine the association between BS on electroencephalogram (EEG) under general anaesthesia with postoperative wake-up delirium and multiple adverse outcomes, such as prolonged awakening and extubation. METHODS In this prospective, observational cohort study at Beijing Children's Hospital, Capital Medical University, Beijing, China, children aged 6 months to 9 years who underwent surgery under general anaesthesia and underwent EEG monitoring between January 2022 and January 2023 were included. Patients' prefrontal EEGs were recorded intraoperatively as well as analysed for the occurrence and duration of BS and scored postoperatively for delirium by the PAED scale, with a score of no less than 10 considered as having developed wake-up delirium. DISCUSSION This study identified a relationship between EEG BS and postoperative awakening delirium under general anaesthesia in children and provides a novel preventive strategy for postoperative awakening delirium and multiple adverse outcomes in paediatric patients. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2200055256. Registered on January 5, 2022.
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Affiliation(s)
- Qian Xu
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
| | - Jianmin Zhang
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China.
| | - Zhengzheng Gao
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
| | - Shanshan Li
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
| | - Gan Li
- Department of Anesthesiology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No.56, South Lishi Road, Beijing, 100045, China
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Tang X, Zhang M, Yang L, Tao X, Li Y, Wang Y, Wang X, Hu X. Individual cartoon video for alleviating perioperative anxiety and reducing emergence delirium in children: a prospective randomised trial. BMJ Paediatr Open 2023; 7:e001854. [PMID: 37407252 DOI: 10.1136/bmjpo-2023-001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Perioperative anxiety and emergence delirium (ED) in young children may cause a series of adverse events, which are worth investigating. Pharmacological treatments of anxiety and delirium remain uncertain, while non-pharmacological treatments lack personalization and pertinence. AIMS The aim of study was to determine whether an individual cartoon video can alleviate perioperative anxiety and reduce ED in young children undergoing adenoidectomy and tonsillectomy. METHODS Children between 3 and 7 years old undergoing adenoidectomy and tonsillectomy were randomly assigned to an individual cartoon video group (group V) or a control group (group C). In group V, an individual cartoon video of the child' s own choice was played throughout the whole waiting, anaesthesia induction and recovery periods. The children in group C were contacted through verbal conversation. The primary outcomes were anxiety measured by the Modified Yale Preoperative Anxiety Scale and ED assessed by the Paediatric Anaesthesia Emergence Delirium (PAED) scale. The secondary outcomes included cooperation during induction, postoperative pain and adverse events. RESULTS The incidence of anxiety were comparable in group V and group C at the holding area (T0) (26% vs 22%, p=0.323), but the incidence of anxiety of group V were significantly lower than those of group C at the time of entering the operating room (T1), during the induction of anaesthesia (T2) and leaving the post anaesthesia care unit (T6) (p<0.001, p<0.001, p<0.001) after intervention. The peak PAED score in group V was significantly lower than that in group C (12.00 (9.00-13.00) vs 13.50 (10.00-15.00), p=0.016). We found no significant differences in cooperation during induction, postoperative pain or the incidence of adverse events between the groups (2.00 (0.00-4.00) vs 3.00 (1.25-4.00), p=0.110; F=0.059, Pgroup=0.808; 3 (7.5%) vs 4 (10), p=0.692). CONCLUSIONS The individual cartoon video is an effective method of reducing perioperative anxiety and alleviating ED in children. TRIAL REGISTRATION NUMBER ChiCTR2200062300 (https://www.chictr.org.cn/index.aspx).
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Affiliation(s)
- Xinyu Tang
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, China
| | - Muchun Zhang
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, China
| | - Lizhuang Yang
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, Anhui, China
| | | | - Yamei Li
- Anhui Medical University, Hefei, China
| | - Yi Wang
- Anhui Medical University, Hefei, China
| | - Xin Wang
- Anhui Medical University, Hefei, China
| | - Xianwen Hu
- Department of Anesthesiology, The Second Hospital of Anhui Medical University, Hefei, Anhui, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, Anhui, China
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Li L, Gao Z, Zhang J, Zhang F, Wang F, Wang X, Li G. Reduced regional cerebral oxygen saturation increases risk for emergence delirium in pediatric patients. Front Pediatr 2023; 11:1117455. [PMID: 37360360 PMCID: PMC10285695 DOI: 10.3389/fped.2023.1117455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Objectives To assess whether decreased regional cerebral oxygen saturation (rScO2) is associated with the emergence delirium (ED) following general anesthesia in the pediatric population. Methods A retrospective observational cohort study was conducted on 113 children (ASA I-III) aged 2-14 years who underwent selective surgery under general anesthesia between 2022-01 and 2022-04. Intraoperatively, the rScO2 was monitored using a cerebral oximeter. The Pediatric Anesthesia Emergence Delirium (PAED) score was used to evaluate the patients for ED. Results The incidence of ED was 31%. Low rScO2 was reported in 41.6% of patients, who had a higher incidence of ED (P < 0.001) than those who did not experience desaturation. Logistic regression analysis revealed that decreased rScO2 was significantly associated with incident ED events [odds ratio (OR), 10.77; 95% confidence interval, 3.31-35.05]. Children under 3 years of age had a higher incidence of ED after rScO2 desaturation during anesthesia compared to older children (OR, 14.17 vs. 4.64). Conclusion Intraoperative rScO2 desaturation significantly increased the incidence of ED following general anesthesia. Monitoring should be enhanced to improve the oxygen balance in vital organs to improve the quality and safety of anesthesia.
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Wang K, Cai J, Du R, Wu J. Global trends in research related to emergence delirium, 2012–2021: A bibliometric analysis. Front Psychol 2023; 14:1098020. [PMID: 36968713 PMCID: PMC10031052 DOI: 10.3389/fpsyg.2023.1098020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/16/2023] [Indexed: 03/10/2023] Open
Abstract
IntroductionEmergence delirium is a kind of mental disorder during the early awakening period after general anesthesia, which is manifested as the combination of perceptual disturbance and psychomotor agitation. It is an independent risk factor for postoperative delirium and even long-term postoperative cognitive decline, which often affects the postoperative outcome and deserves the attention of clinical anesthesiologists. There are many studies on emergence delirium, but the quantity and quality of these studies are unclear. Therefore, we conducted a bibliometric analysis of studies on emergence delirium between January 2012 and December 2021. Through the analysis of relevant literature, the research hotspots and trends of emergence delirium are understood, which can provide a reference for future research.MethodsWe searched the Web of Science Core Collection (WoSCC) for original articles and reviews related to emergence delirium published between 2012 and 2021, and collected a variety of bibliographic elements, including annual publications, authors, countries/regions, institutions, journals, and keywords. Three different science-based tools (CiteSpace, VOSviewer and Bibliometrix) were used for this comprehensive analysis.ResultsFrom January 2012 to December 2021, a total of 912 emergence delirium (ED) related literature were published, including 766 original research articles and 146 review articles. The number of publications has increased every year except 2016. The United States published 203 articles, ranking first with China, followed by South Korea (95 articles). The United States is also the country with the most citations (4,508), and Yonsei Univ is the most productive institution. The most published journal was PEDIATRIC ANESTHESIA, with the highest h and g index. LEE JH is the most influential author in this field.Discussion“Children, emergence agitation, delirium, dexmedetomidine” are the hot topics in this field in recent years. The bibliometric analysis in this field will provide the future direction for the study of emergence delirium for clinicians.
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Affiliation(s)
- Kenru Wang
- Department of Anesthesia, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jiehui Cai
- Department of General Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
- *Correspondence: Jiehui Cai,
| | - Ruiming Du
- Department of Anesthesia, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Ruiming Du,
| | - Jiaxuan Wu
- Department of Anesthesia, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Jiaxuan Wu,
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Cardiorespiratory Response to Sedative Premedication in Preschool Children: A Randomized Controlled Trial Comparing Midazolam, Clonidine, and Dexmedetomidine. J Perianesth Nurs 2023; 38:454-460. [PMID: 36604221 DOI: 10.1016/j.jopan.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Sedative premedication in children may negatively impact their cardiorespiratory status during the perioperative course, and no clear consensus exists on the optimal premedication treatment for pediatric patients. The objective was to compare the perioperative cardiorespiratory responses to sedation using three different sedative premedication regimens in preschool children scheduled for surgery with total intravenous anesthesia. DESIGN A single-center randomized controlled trial. METHODS This is a planned secondary analysis of a study conducted at a 200-bed tertiary referral hospital. Ninety children participated in the study. They were aged 2-6 years and scheduled for ear, nose, and throat surgery with propofol/remifentanil anesthesia. Participants were randomly assigned to receive oral midazolam 0.5 mg/kg-1 (MID), oral clonidine 4 mcg/kg-1 (CLO), or intranasal dexmedetomidine 2 mcg/kg-1 (DEX). The main outcome measures were the sedation level, based on the Ramsay Sedation Scale (RSS), and cardiorespiratory status, monitored during the perioperative period. FINDINGS The final cohort had 83 children (MID, n=27; CLO, n=26; DEX, n=30), with similar intergroup patient characteristics. RSS scores were lower in the MID group than in the CLO and DEX groups before induction and within 30 min postsurgery (P<0.001 and P=0.006, respectively). A negative correlation existed between the RSS and heart rate (HR) (r=-0.570, P<0.001). Before anesthesia induction, the respiratory rate was lowest in the DEX group (MID 21.5±1.7 min-1, CLO 20.6±2.6 min-1, DEX 20.2±1.7 min-1; P=0.042). The HR was lower in the CLO and DEX groups than in the MID group (MID, 102.8±10.0 min-1; CLO, 87.4±9.6 min-1; DEX, 87.6±7.9 min-1; P<0.001). The HR was lower immediately after induction (P=0.009) and intraoperatively (P=0.025) in the CLO and DEX groups than in the MID group. CONCLUSIONS When used as premedication before propofol/remifentanil anesthesia, clonidine and dexmedetomidine provided deeper preoperative sedation compared to midazolam. From a clinical perspective, all three study drugs provided essentially stable cardiovascular and respiratory conditions during the entire perioperative period.
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Quintão VC, Carlos RV, Kulikowski LD, Lee-Archer P, Carmona MJC. Association between adult and child behavioral interactions with preoperative anxiety and emergence delirium. Paediatr Anaesth 2022; 33:402-404. [PMID: 36567612 DOI: 10.1111/pan.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Vinícius Caldeira Quintão
- Discipline of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Instituto da Criança e do Adolescente, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ricardo Vieira Carlos
- Discipline of Anesthesiology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Instituto da Criança e do Adolescente, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Leslie Domenici Kulikowski
- Laboratório de Citogenômica LIM-3, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Paul Lee-Archer
- Department of Anesthesia, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Taylor M, Pileggi W, Boland M, Boudreaux-Kelly M, Julian D, Beckstead A. A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center. PATIENT SAFETY 2022. [DOI: 10.33940/med/2022.12.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table.
A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention.
To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.
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Affiliation(s)
| | | | | | | | - David Julian
- VA Pittsburgh Healthcare System; University of Pittsburgh Medical Center Altoona
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13
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Taylor M, Pileggi W, Boland M, Boudreaux-Kelly M, Julian D, Beckstead A. Online Supplement to “A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veteran Affairs Medical Center”. PATIENT SAFETY 2022. [DOI: 10.33940/supplement/2022.12.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This supplementary material was provided by the authors to give readers additional information and resources to replicate their work.
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Affiliation(s)
| | | | | | | | - David Julian
- VA Pittsburgh Healthcare System; University of Pittsburgh Medical Center Altoona
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Fernstrum C, Deichmann P, Duncan F, Humphries L, Hoppe I. A standardized approach to airway management during Abbé flap reconstruction. Paediatr Anaesth 2022; 32:1305-1309. [PMID: 36086897 DOI: 10.1111/pan.14554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Abbé flap is a two-staged procedure to address upper lip tightness, creating a surgically closed mouth during the first stage. Airway manipulation and management in the setting of a surgically closed mouth presents a challenge from an anesthetic standpoint. AIMS This study aims to describe the authors' standardized approach to airway management in cleft lip patients undergoing Abbé flap reconstruction. METHODS A retrospective review was performed including consecutive patients who underwent Abbe flap reconstruction at a single institution from 2019 to 2021. Five patients were included, and information regarding airway, intubation sequence, and emergence was gathered. RESULTS During the initial surgery, the airway was secured via nasotracheal intubation to allow for adequate surgical exposure. On emergence, with a newly constructed surgically closed mouth, the anesthesiologist forfeits the ability to reintubate should the patient fail extubation without the use of nasal fiberoptic guided intubation or flap deinset. In addition, any coughing or tension on the surgical site could cause inadvertent disruption to the integrity of the new flap. Dexmedetomidine titrated to effect was used to allow for smooth emergence, with the surgeon present. During the second stage, the patient was kept spontaneously breathing while local anesthetic and intravenous anxiolytic allowed for pedicle division. The patient was then orally intubated, and the flap was inset. All five patients had successful reconstruction with no airway concerns or events. CONCLUSIONS The proposed standardized approach to airway management during Abbé flap reconstruction was safe and effective in this limited series of patients.
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Affiliation(s)
- Colton Fernstrum
- Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Paige Deichmann
- Pediatric Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Forrest Duncan
- Pediatric Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Laura Humphries
- Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ian Hoppe
- Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
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15
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Spanish version of the Pediatric Anesthesia Emergence Delirium scale: translation and cross-cultural adaptation. BMC Anesthesiol 2022; 22:349. [PMID: 36376787 PMCID: PMC9661762 DOI: 10.1186/s12871-022-01893-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background Emergence delirium (ED) is a mental disturbance in children during recovery from general anaesthesia. The Pediatric Anesthesia Emergence Delirium (PAED) scale is the only validated scale that assesses ED in paediatric patients undergoing general anaesthesia. The aim of this study was the translation and cross-cultural adaptation of the PAED scale into Spanish (Chile). Methods A five-stage translation and cross-cultural adaptation process was carried out. The reliability of the Spanish version of the PAED scale was evaluated in paediatric patients independently by a set of two raters (anaesthesiologists or postanaesthesia care unit nurses) in the postanaesthetic period after major outpatient surgery. ED was defined by a cut-off level of ≥ 10 points on the PAED scale. Results The PAED scale was evaluated in 353 consecutive children. Patients had a mean age of 7.4 ± 3.22 years. The preoperative ASA Physical Status class was 62%, 37%, and 1% (ASA class I, II and III, respectively). The distribution of patients by service was as follows: 45% of patients underwent paediatric surgery; 33% underwent otorhinolaryngological surgery; 11% underwent orthopaedic surgery; 10% underwent ophthalmological surgery; and 1% underwent other types of surgery. The interrater agreement ranged from 96.9% to 97.9%, with Kappa values ranging from 0.59 to 0.79. The Cronbach’s alpha value was 0.91. The ED global incidence was 9.1% and was higher in the younger age groups (3–10 years). Conclusions The translated and cross-culturally adapted Spanish version of the PAED scale is a reliable instrument to measure ED in the postanaesthetic period in Chilean children.
Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01893-1.
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Yuan I, Missett RM, Jones-Oguh S, Massa CB, Babus LW, Garcia-Marcinkiewicz AG, Daly Guris RJ, Johnson G, McClung-Pasqualino H, Sequera-Ramos L, Iyer RS, Kurth CD. Implementation of an electroencephalogram-guided propofol anesthesia education program in an academic pediatric anesthesia practice. Paediatr Anaesth 2022; 32:1252-1261. [PMID: 35793171 DOI: 10.1111/pan.14520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/19/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Propofol total intravenous anesthesia (TIVA) is increasingly popular in pediatric anesthesia, but education on its use is variable and over-dosage adverse events are not uncommon. Recent work suggests that electroencephalogram (EEG) parameters can guide propofol dosing in the pediatric population. This education quality improvement project aimed to implement a standardized EEG TIVA training program over 12 months in a large pediatric anesthesia division. METHODS The division consisted of 63 faculty, 11 clinical fellows, 32 residents, and 28 nurse anesthetists at the Children's Hospital of Philadelphia. The program was assessed for effectiveness (a significant improvement in EEG knowledge scores), scalability (training 50% of fellows and staff), and sustainability (recurring EEG lectures for 80% of rotating residents and 100% of new fellows and staff). The key drivers included educational content development (lectures, articles, and hand-outs), training a cohort of EEG TIVA trainers, intraoperative teaching (teaching points and dosing tables), decision support tools (algorithms and anesthesia electronic record pop-ups), and knowledge tests (written exam and verbal quiz during cases). RESULTS Over 12 months, 78.5% of the division (62/79) completed EEG training and test scores improved (mean score 38% before training vs 59% after training, p < .001). Didactic lectures were given to 100% of the fellows, 100% (11/11) of new staff, and 80% (4/5 blocks) of rotating residents. CONCLUSION This quality improvement education project successfully trained pediatric anesthesia faculty, staff, residents, and fellows in EEG-guided TIVA. The training program was effective, scalable, and sustainable over time for newly hired faculty staff and rotating fellows and residents.
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Affiliation(s)
- Ian Yuan
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Richard M Missett
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Sheri Jones-Oguh
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Christopher B Massa
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Lenard W Babus
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Annery G Garcia-Marcinkiewicz
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Rodrigo J Daly Guris
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Gregory Johnson
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Heather McClung-Pasqualino
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Luis Sequera-Ramos
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Rajeev Subramanyam Iyer
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
| | - Charles D Kurth
- Children's Hospital of Philadelphia Ringgold standard institution - Anesthesiology and Critical Care Philadelphia, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine Ringgold standard institution - Anesthesiology, Philadelphia, Pennsylvania, USA
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Modi D, Goyal S, Kothari N, Sharma A, Kumar R, Chhabra S, Goel A, Bhatia P. Comparison of incidence of emergence delirium in pediatric patients with three different techniques of general anesthesia using sevoflurane and propofol: a randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:841-842. [PMID: 35605692 PMCID: PMC9660000 DOI: 10.1016/j.bjane.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/26/2022] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Deepak Modi
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Shilpa Goyal
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India.
| | - Nikhil Kothari
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Ankur Sharma
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Trauma & Emergency (Anaesthesiology), Rajasthan, India
| | - Rakesh Kumar
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Swati Chhabra
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
| | - Akhil Goel
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Community Medicine and Family Medicine, Rajasthan, India
| | - Pradeep Bhatia
- All India Institute of Medical Sciences (AIIMS) Jodhpur, Department of Anaesthesiology and Critical Care, Rajasthan, India
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"You're O.K. Anesthesia": Closed Reduction of Displaced Pediatric Forearm and Wrist Fractures in the Office Without Anesthesia. J Pediatr Orthop 2022; 42:595-599. [PMID: 35993589 DOI: 10.1097/bpo.0000000000002246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Angulated wrist and forearm fractures are among the most common pediatric fractures, and they often require closed reduction with anesthesia. There are several issues associated with pediatric anesthesia including the low but non-zero risk of significant complications, increased physician and staff time and effort, and increased cost. Despite these issues, there have not been any studies to prove that using anesthesia results in better outcomes or higher caregiver satisfaction in comparison to performing closed reductions without anesthesia. The purpose of this study was to evaluate the quality of closed reductions of angulated pediatric wrist and forearm fractures and to determine caregiver satisfaction with an anesthesia-free reduction technique. METHODS This study included 54 pediatric patients with closed, angulated fractures of the radius or combined radial and ulnar shafts. All closed reductions were performed by a single pediatric fellowship-trained orthopaedic surgeon in the office setting without any anesthesia. Radiographs were obtained to assess the quality of the reduction. At the first follow-up visit, caregivers were asked about their interim use of pain medications. Caregivers were later surveyed about patient use of analgesics and their satisfaction with an anesthesia-free reduction technique. RESULTS The average age of the 54 patients in this study was 9 years (1.8 to 16.8 y). Thirty-three fractures were combined radial and ulnar forearm shaft fractures, 18 were distal radius fractures, and 3 were radial shaft fractures. ≤10 degrees of residual angulation was achieved in 98% of patients. Nine percent (5/54) of the patients used ibuprofen or acetaminophen for pain control. Seventy eight percent (42/54) of the caregivers responded to the telephone and email surveys. All responding caregivers stated that the patients returned to full function and had satisfactory outcomes. Ninety eight percent (41/42) of the caregivers stated they would choose the same anesthesia-free reduction technique again. CONCLUSIONS Closed reduction of angulated pediatric wrist and forearm fractures in the office without anesthesia can achieve satisfactory reductions and high caregiver satisfaction while eliminating the risks and complications associated with pediatric anesthesia. LEVEL OF EVIDENCE Level IV Case series.
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Li Y, Li J, Shi Y, Zhou X, Feng W, Han L, Ma D, Jiang H, Yuan Y. Urinary Aromatic Amino Acid Metabolites Associated With Postoperative Emergence Agitation in Paediatric Patients After General Anaesthesia: Urine Metabolomics Study. Front Pharmacol 2022; 13:932776. [PMID: 35928271 PMCID: PMC9343964 DOI: 10.3389/fphar.2022.932776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Emergence agitation (EA) is very common in paediatric patients during recovery from general anaesthesia, but underlying mechanisms remain unknown. This prospective study was designed to profile preoperative urine metabolites and identify potential biomarkers that can predict the occurrence of EA. Methods: A total of 224 patients were screened for recruitment; of those, preoperative morning urine samples from 33 paediatric patients with EA and 33 non-EA gender- and age-matched patients after being given sevoflurane general anaesthesia were analysed by ultra-high-performance liquid chromatography (UHPLC) coupled with a Q Exactive Plus mass spectrometer. Univariate analysis and orthogonal projection to latent structures squares-discriminant analysis (OPLS-DA) were used to analyse these metabolites. The least absolute shrinkage and selection operator (LASSO) regression was used to identify predictive variables. The predictive model was evaluated through the receiver operating characteristic (ROC) analysis and then further assessed with 10-fold cross-validation. Results: Seventy-seven patients completed the study, of which 33 (42.9%) patients developed EA. EA and non-EA patients had many differences in preoperative urine metabolic profiling. Sixteen metabolites including nine aromatic amino acid metabolites, acylcarnitines, pyridoxamine, porphobilinogen, 7-methylxanthine, and 5′-methylthioadenosine were found associated with an increased risk of EA, and they all exhibited higher levels in the EA group than in the non-EA group. The main metabolic pathways involved in these metabolic changes included phenylalanine, tyrosine and tryptophan metabolisms. Among these potential biomarkers, L-tyrosine had the best predictive value with an odds ratio (OR) (95% CI) of 5.27 (2.20–12.63) and the AUC value of 0.81 (0.70–0.91) and was robust with internal 10-fold cross-validation. Conclusion: Urinary aromatic amino acid metabolites are closely associated with EA in paediatric patients, and further validation with larger cohorts and mechanistic studies is needed. Clinical Trial Registration:clinicaltrials.gov, identifier NCT04807998
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Affiliation(s)
- Yueyue Li
- Department of Pharmacy, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jingjie Li
- Department of Anaesthesiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuhuan Shi
- Department of Pharmacy, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xuhui Zhou
- Department of Anaesthesiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanqing Feng
- Department of Anaesthesiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu Han
- Department of Pharmacy, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
| | - Hong Jiang
- Department of Anaesthesiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Hong Jiang, ; Yongfang Yuan,
| | - Yongfang Yuan
- Department of Pharmacy, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
- *Correspondence: Hong Jiang, ; Yongfang Yuan,
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Simonini A, Brogi E, Cascella M, Vittori A. Advantages of ketamine in pediatric anesthesia. Open Med (Wars) 2022; 17:1134-1147. [PMID: 35859796 PMCID: PMC9263896 DOI: 10.1515/med-2022-0509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 12/29/2022] Open
Abstract
Although ketamine is primarily used for induction and maintenance of general anesthesia, it also presents sedative, amnestic, anesthetics, analgesic, antihyperalgesia, neuroprotective, anti-inflammatory, immunomodulant, and antidepressant effects. Its unique pharmacodynamics and pharmacokinetic properties allow the use of ketamine in various clinical settings including sedation, ambulatory anesthesia, and intensive care practices. It has also adopted to manage acute and chronic pain management. Clinically, ketamine produces dissociative sedation, analgesia, and amnesia while maintaining laryngeal reflexes, with respiratory and cardiovascular stability. Notably, it does not cause respiratory depression, maintaining both the hypercapnic reflex and the residual functional capacity with a moderate bronchodilation effect. In the pediatric population, ketamine can be administered through practically all routes, making it an advantageous drug for the sedation required setting such as placement of difficult vascular access and in uncooperative and oppositional children. Consequently, ketamine is indicated in prehospital induction of anesthesia, induction of anesthesia in potentially hemodynamic unstable patients, and in patients at risk of bronchospasm. Even more, ketamine does not increase intracranial pressure, and it can be safely used also in patients with traumatic brain injuries. This article is aimed to provide a brief and practical summary of the role of ketamine in the pediatric field.
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Affiliation(s)
- Alessandro Simonini
- Department of Pediatric Anaesthesia and Intensive Care, S.C. SOD Anestesia e Rianimazione Pediatrica, Ospedale G. Salesi , Ancona , 60123 , Italy
| | - Etrusca Brogi
- Department Anesthesia and Intensive Care, University of Pisa , Pisa , 56126 , Italy
| | - Marco Cascella
- Department of Supportive Care, Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale , Naples , 80100 , Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO Roma Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4 , 00165 , Rome , Italy
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Gao Z, Zhang J, Nie X, Cui X. Effectiveness of Intravenous Ibuprofen on Emergence Agitation in Children Undergoing Tonsillectomy with Propofol and Remifentanil Anesthesia: A Randomized Controlled Trial. J Pain Res 2022; 15:1401-1410. [PMID: 35592817 PMCID: PMC9113115 DOI: 10.2147/jpr.s363110] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Emergence agitation (EA) has a negative effect on the recovery from general anesthesia in children. This study aimed to evaluate the effectiveness of intravenous ibuprofen in reducing the incidence of EA in children. Methods This randomized, double-blind, placebo-controlled, single-center study analyzed data from patients aged 3–9 years undergoing tonsillectomy under general anesthesia with propofol and remifentanil. These patients were randomly assigned to receive either the ibuprofen or the placebo intraoperatively. The primary endpoint was a between-group difference in the incidence of EA at 15 min following extubation. EA was defined as Pediatric Anesthesia Emergence Delirium score ≥10. The secondary endpoint included the associated factors of EA. Results Eighty-nine patients were included in the study. Ibuprofen decreased the incidence of EA at 15 min following extubation (8.9% in the treatment group vs 34.1% in the control group; odds ratio [OR], 0.261; 95% confidence interval [CI], 0.094–0.724; P=0.004). Compared with the control group, there was a significant reduction in the number of rescue fentanyl doses (P=0.045), and fewer patients experienced moderate to severe pain at 15 min following extubation in the treatment group (P=0.048). Upon logistic regression analysis, high modified Pediatric Anesthesia Behavior and pain scores following surgery were considered the risk factors related to EA (OR, 8.07; 95% CI, 1.12–58.07, P=0.038 and OR, 2.78; 95% CI, 1.60–4.82, P<0.001, respectively). Ibuprofen administration was the protective factor related to EA (OR, 0.05; 95% CI, 0.01–0.67, P=0.023). Conclusion Intraoperative ibuprofen infusion can significantly reduce the incidence of EA following general anesthesia with propofol and remifentanil in children. Trial Registration The study was registered with the Chinese Clinical Trial Registry on 7 April 2021 (number: ChiCTR2100045128; https://www.chictr.org.cn/edit.aspx?pid=124595&htm=4).
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Affiliation(s)
- Zhengzheng Gao
- Department of Anesthesiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, People’s Republic of China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, People’s Republic of China
- Correspondence: Jianmin Zhang, Department of Anesthesiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56 South Lishi Road, Xicheng District, Beijing, 100045, People’s Republic of China, Tel +86 10-59616415, Email
| | - Xiaolu Nie
- Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, People’s Republic of China
| | - Xiaohuan Cui
- Department of Anesthesiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, People’s Republic of China
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Coşkun AS. Comparing the effects of propofol and ketamine on the emergence agitation of male children undergoing circumcision. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-021-00136-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Separation from the family, prolonged hunger, inability to perceive the surgical procedure performed, and feeling pain are among the main reasons for agitation in young children. In operations like circumcision, in which all bodily integrity is disrupted and children cannot make sense of it and feel punished, this agitation increases. The aim of the present study was to compare the effects of propofol and ketamine on the emergence agitation (EA) in children undergoing circumcision.
Result
When the patients were taken to post-anesthesia care unit (PACU), no statistically significant difference was observed between propofol and ketamine groups in the Aono’s four-point scale at minute 0 (p = 0.073). In the 5th minute, it was higher in the ketamine group compared to the propofol group (p < 0.001). With Aono’s four-point scale, EA diagnosis is made in areas with 3 and 4 points. The average Aono’s four-point scale in the ketamine group at the 5th minute was 3.08 ± 1.02. Since the Modified Steward score was ≥ 6, the time taken was longer in the ketamine group compared to the propofol group (p < 0.001).
Conclusion
EA does not only occur in inhalational anesthetics, it is also seen with ketamine. In view of the fact that ketamine can cause EA in children, it should not be used alone in anesthesia. Propofol provides a safe anesthesia. Instead of inhalational anesthesia, where the type of surgery is suitable, anesthesia with propofol infusion should be applied. Further research is required to investigate EA.
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Wang Y, Zhao L, Zhang C, An Q, Guo Q, Geng J, Guo Z, Guan Z. Identification of risk factors for postoperative delirium in elderly patients with hip fractures by a risk stratification index model: A retrospective study. Brain Behav 2021; 11:e32420. [PMID: 34806823 PMCID: PMC8671782 DOI: 10.1002/brb3.2420] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/29/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Postoperative delirium is one of the most common and dangerous psychiatric complications after hip surgery. The aim of this study was to investigate the incidence of postoperative delirium in elderly patients after hip fracture surgery and to identify risk factors for such, as part of developing a risk stratification index (RSI) system to predict a patient's risk of postoperative delirium. METHODS Elderly patients (aged 65 years or older) with hip fractures who had received surgical treatment in our hospital between March 2018 and December 2019 were retrospectively included. Clinical data were collected, and multivariate logistic regression analysis was performed to investigate the relevant risk factors of postoperative delirium. An RSI system was developed based on factors identified in the regression analysis. RESULTS Of 272 patients included, 52 (19.12%) experienced postoperative delirium. Drinking history (> 3/ week), the perioperative lactic acid level (Lac > 2 mmol/L), postoperative visual analog score (VAS) > 3, American Society of Anesthesiologists (ASA) physical status > II, application of the bispectral index, and preoperative diabetes were independent risk factors of postoperative delirium. When RSI ≥ 5, the rate of postoperative delirium significantly increased (p < .05). CONCLUSION The RSI system developed here can safely guide postoperative outcomes of elderly patients with hip fractures, and RSI ≥ 5 may be able to predict the onset of postoperative delirium.
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Affiliation(s)
- Ye Wang
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Lin Zhao
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Changsheng Zhang
- The Anesthesia and Operation Center, The First Medical Center, The Medical School of Chinese PLA, Beijing, China
| | - Qi An
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Qianqian Guo
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Jie Geng
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Zhenggang Guo
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Zhengpeng Guan
- The Department of Orthopedics, Peking University Shougang Hospital, Beijing, China
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A Comparison of Dexmedetomidine and Propofol on Emergence Delirium in Children Undergoing Cleft Palate Surgery With Sevoflurane-Based Anesthesia. J Craniofac Surg 2021; 33:650-653. [PMID: 34739450 DOI: 10.1097/scs.0000000000008343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
ABSTRACT Emergence delirium is a common complication after sevoflurane-anesthesia and have a serious impact on children undergoing cleft palate surgery. The aim of this study was to compare the effect of propofol and dexmedetomidine on emergence delirium in children. Ninety children aged 8 to 24 months, underwent cleft palate repair, were enrolled in the study. Children were randomly assigned to 3 groups after the induction: Group C (intravenous infusion 0.9% saline), Group P (intravenous infusion 2 mg/kg/hour propofol), and Group D (intravenous infusion 0.5 μg/kg/hour dexmedetomidine). Emergence delirium was diagnosed using the pediatric anesthesia emergence delirium scale and pain using the face, legs, activity, cry, consolability scale. Heart rate, mean arterial pressure, respiratory recovery time, extubation time, post anesthesia care unit observation time, and adverse events were also evaluated. A total of 86 patients were analyzed. The incidence of emergence delirium was 20.1% in group D, 58.6% in group P and 85.7% in group C (P < 0.05). A lower face, legs, activity, cry, consolability score was seen in group D than in group P and group C (3.9 + 1.1 versus 6.1 ± 0.9 and 7.1 ± 1.0, P < 0.05). The value of heart rate and mean arterial pressure during emergence in group P and group C were significantly higher than that in group D (All P < 0.05). These findings suggest that dexmedetomidine as a sedative, analgesic, and sympatholytic agent was superior to propofol in reducing the incidence of emergence delirium in children undergoing cleft palates surgery with sevoflurane-based anesthesia.
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Emergence Delirium in a 29-Year-Old Man following an Uneventful Appendectomy. Case Rep Med 2021; 2021:1338823. [PMID: 34608393 PMCID: PMC8487383 DOI: 10.1155/2021/1338823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/01/2021] [Accepted: 09/11/2021] [Indexed: 02/07/2023] Open
Abstract
Emergence delirium (ED) is defined as the delirium that occurs during the transition from the sleep state to full consciousness. ED increases the risk for injury, self-extubation, hemorrhages, and prolonged hospitalization and occurs in patients of any age but most often in children and elderly patients. However, ED in young adults is rarely reported. We presented a case of typical ED occurring in a young healthy man following an uneventful appendectomy. The causes of ED can be classified as either predisposing or precipitating factors. In this case, the unnoticeable mental stress may be the predisposing factor and the sevoflurane maintenance of anesthesia may be the precipitating factor. ED occurs at any age of patient and in any minor surgery, and anesthesiologists should do some work to prevent it from happening.
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Adler AC, Nathanson BH, Chandrakantan A. Monochromic light reduces emergence delirium in children undergoing adenotonsillectomy; a double-blind randomized observational study. BMC Anesthesiol 2021; 21:217. [PMID: 34496743 PMCID: PMC8424999 DOI: 10.1186/s12871-021-01435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/28/2021] [Indexed: 11/27/2022] Open
Abstract
Background Emergence delirium (ED) is common in pediatric anesthesia. This dissociative state in which the patient is confused from their surroundings and flailing can be self-injurious and traumatic for parents. Treatment is by administration of sedatives which can prolong recovery. The aim of this study was to determine if exposure to monochromatic blue light (MBL) in the immediate phase of recovery could reduce the overall incidence of emergence delirium in children following general inhalational anesthesia. Methods This double blinded randomized controlled study included patients ages 2–6 undergoing adenotonsillectomy. Postoperatively, 104 patients were randomization (52 in each group) for exposure to sham blue or MBL during the first phase (initial 30 min) of recovery. The primary outcome was the incidence of emergence delirium during the first phase. We also examined Pediatric Anesthesia Emergence Delirium (PAED) scores throughout the first phase. Results Emergence Delirium was reported in 5.9% of MBL patients versus 33.3% in the sham group, p = 0.001. Using logistic regression adjusting for age, weight, gender, ASA classification and PAED scores provided an adjusted relative risk ratio of 0.18; 95% CI (0.06, 0.54); p = 0.001 for patients in the MBL group. 23.5% of MBL patients versus 52.9% of sham patients had either ED or PAED scores of 12 or more throughout the first phase of recovery, p = 0.002. This produced an adjusted relative risk of 0.46, 95% CI (0.29, 0.75), p = 0.001. Conclusions Monochromatic blue light represents a non-pharmacologic method to reduce the incidence of emergence delirium and PAED scores in children. Trial Registration #NCT03285243 registered on 15/09/2017 Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01435-1.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, USA. .,Baylor College of Medicine, Houston, TX, USA.
| | | | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
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Effectiveness and Safety of Intravenous Sedation with Propofol in Non-Operating Room Anesthesia (NORA) for Dental Treatment in Uncooperative Paediatric Patients. CHILDREN-BASEL 2021; 8:children8080648. [PMID: 34438539 PMCID: PMC8392425 DOI: 10.3390/children8080648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/13/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022]
Abstract
Background: Uncooperative children require sedative approach for dental treatment. The aim was to assess the effectiveness of Propofol in “Non-Operating Room Anesthesia” (NORA) for paediatric dental treatment; intraoperative side effects; postoperative side effects; post-discharge effects. Methods: a prospective study, involving 109 uncooperative children undergoing sedation in NORA using Propofol for dental treatment, was performed. Working sessions, success/failure, intraoperative and postoperative side effects, number of treatment; type of procedure were assessed. Parents completed a post-discharge questionnaire on: pain; crying; fever; vomiting; headache; drowsiness; excitability; irritability; ability to eat; drugs and medical care needing. Results: Success: 96.7%. Intraoperative side effects: 33.3%. Postoperative side effects: 6.4%. Statistically significant association between: intraoperative side effects and age (p = 0.001), health status (p = 0.0007), weight (p = 0.038), respectively; intraoperative side effects and number/ type of dental treatment (p = 0.0055) and scaling (p = 0.0001), respectively. For post-discharge questionnaires, statistically significant association between: age and crying (p = 0.0001) and headache (p = 0.002), respectively; health status and crying (p = 0.015) and drugs needing (p = 0.04), respectively; weight and crying (p = 0.0004); extraction and pain (p = 0.0001) and crying (p= 0.0073), respectively; scaling and crying (p = 0.04), excitability and irritability (p = 0.03), respectively. Conclusion: Propofol in NORA was effective with minimal side effects.
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Biliškov AN, Ivančev B, Pogorelić Z. Effects on Recovery of Pediatric Patients Undergoing Total Intravenous Anesthesia with Propofol versus Ketofol for Short-Lasting Laparoscopic Procedures. CHILDREN-BASEL 2021; 8:children8070610. [PMID: 34356589 PMCID: PMC8303649 DOI: 10.3390/children8070610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 06/25/2021] [Accepted: 07/15/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Combining ketamine and propofol (ketofol) was suggested as a new concept for sedation and general anesthesia in pediatric populations for various conditions. The aim of the present study was to determine the effect of total intravenous anesthesia (TIVA) with propofol and ketofol on recovery after laparoscopic surgery in pediatric patients. METHODS Two hundred children with median age of 5 years who underwent laparoscopic surgery were randomized into two groups. Propofol 1% was used for induction and maintenance of anesthesia in group I, while ketamine-propofol combination (ketofol) was used in group II. Ketamine-propofol combination (ketofol) was prepared in the same applicator for group II. Ketofol ratios of 1:4 and 1:7 were used for induction and maintenance of anesthesia, respectively. A reduced McFarlan infusion dose was used in group I (1.2, 1.0, and 0.8 mL/kg/h for 15, 15, and 30 min, respectively), while a McFarlan infusion dose was used in group II (1.5, 1.3, and 1.1 mL/kg/h for 15, 15, and 30 min, respectively). Extubating time, duration of anesthesia, and length of stay in post-anesthesia care unit (PACU) were recorded. RESULTS Extubating time was significantly lower in the ketofol group than in the propofol group (240 s vs. 530 s; p < 0.00001). Significantly shorter duration of anesthesia (47 min vs. 60 min; p < 0.00001) as well as length of stay in the PACU (35 min vs. 100 min; p < 0.00001) were recorded in ketofol compared to the propofol group. Total fentanyl (100 µg (interquartile range, IQR 80, 125) vs. 50 µg (IQR 40, 60); p < 0.00001) and propofol (260 mg (IQR 200, 350) vs. 160 mg (IQR 120, 210); p < 0.00001) consumption per body weight were significantly lower in the ketofol group. CONCLUSIONS TIVA with ketamine-propofol combination (ketofol) using a reduced McFarlan dose regimen shortened extubating time, duration of anesthesia, as well as length of stay in the PACU in pediatric anesthesia after laparoscopic surgery.
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Affiliation(s)
- Ana Nevešćanin Biliškov
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
- Correspondence: ; Tel.: +385-21-556111
| | - Božena Ivančev
- Department of Pediatric Surgery, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia; (B.I.); (Z.P.)
| | - Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia; (B.I.); (Z.P.)
- Department of Surgery, School of Medicine, University of Split, Šoltanska 2, 21000 Split, Croatia
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Heiderich S, Ghasemi T, Dennhardt N, Sümpelmann R, Rigterink V, Nickel K, Keil O, Böthig D, Beck CE. Correlation of exhaled propofol with Narcotrend index and calculated propofol plasma levels in children undergoing surgery under total intravenous anesthesia - an observational study. BMC Anesthesiol 2021; 21:161. [PMID: 34039280 PMCID: PMC8149920 DOI: 10.1186/s12871-021-01368-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exhaled propofol concentrations correlate with propofol concentrations in adult human blood and the brain tissue of rats, as well as with electroencephalography (EEG) based indices of anesthetic depth. The pharmacokinetics of propofol are however different in children compared to adults. The value of exhaled propofol measurements in pediatric anesthesia has not yet been investigated. Breathing system filters and breathing circuits can also interfere with the measurements. In this study, we investigated correlations between exhaled propofol (exP) concentrations and the Narkotrend Index (NI) as well as calculated propofol plasma concentrations. METHODS A multi-capillary-column (MCC) combined with ion mobility spectrometry (IMS) was used to determine exP. Optimal positioning of breathing system filters (near-patient or patient-distant) and sample line (proximal or distal to filter) were investigated. Measurements were taken during induction (I), maintenance (M) and emergence (E) of children under total intravenous anesthesia (TIVA). Correlations between ExP concentrations and NI and predicted plasma propofol concentrations (using pediatric pharmacokinetic models Kataria and Paedfusor) were assessed using Pearson correlation and regression analysis. RESULTS Near-patient positioning of breathing system filters led to continuously rising exP values when exP was measured proximal to the filters, and lower concentrations when exP was measured distal to the filters. The breathing system filters were therefore subsequently attached between the breathing system tubes and the inspiratory and expiratory limbs of the anesthetic machine. ExP concentrations significantly correlated with NI and propofol concentrations predicted by pharmacokinetic models during induction and maintenance of anesthesia. During emergence, exP significantly correlated with predicted propofol concentrations, but not with NI. CONCLUSION In this study, we demonstrated that exP correlates with calculated propofol concentrations and NI during induction and maintenance in pediatric patients. However, the correlations are highly variable and there are substantial obstacles: Without patient proximal placement of filters, the breathing circuit tubing must be changed after each patient, and furthermore, during ventilation, a considerable additional loss of heat and moisture can occur. Adhesion of propofol to plastic parts (endotracheal tube, breathing circle) may especially be problematic during emergence. TRIAL REGISTRATION The study was registered in the German registry of clinical studies (DRKS-ID: DRKS00015795 ).
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Affiliation(s)
- Sebastian Heiderich
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Tara Ghasemi
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nils Dennhardt
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Robert Sümpelmann
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Vanessa Rigterink
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Katja Nickel
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Oliver Keil
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Dietmar Böthig
- Department for Pediatric Cardiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Christiane E Beck
- Clinic of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Houben A, Ghamari S, Fischer A, Neumann C, Baehner T, Ellerkmann RK. Pediatric emergence delirium is linked to increased early postoperative negative behavior within two weeks after adenoidectomy: an observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021:S0104-0014(21)00138-X. [PMID: 33887334 DOI: 10.1016/j.bjane.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/05/2021] [Accepted: 03/13/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this prospective multicenter observational study was to measure the incidence of postoperative pediatric emergence delirium and to investigate the occurrence of early postoperative negative behavior within two weeks after outpatient adenoidectomy in preschool children. METHODS The study comprised 222 patients (1-7 years of age). All children received a multimodal anesthesia based on total intravenous anesthesia with propofol and remifentanil in combination with piritramid (0.1 mg.kg-1), ibuprofen (10 mg.kg-1), dexamethason (0.15 mg.kg-1), and ketanest S (0.1 mg.kg-1). We evaluated emergence delirium using the Pediatric Anesthesia Emergence Delirium Scale (PAED) at different predefined time points during the recovery period. Emergence delirium was defined as a PAED score ≥ 9 for the first three criteria. Additionally, we defined early postoperative negative behavior to be present when at least 5 of 27 criteria of the post hospitalization behavior questionnaire were positive. RESULTS The incidence of emergence delirium following our anesthetic regime was 23%. The incidence of early postoperative negative behavior was significantly higher among patients with emergence delirium (24% vs. 11%, p = 0.04). The two categories, "sleep disturbance" and "separation anxiety", tested within the questionnaire for early postoperative negative behavior, were identified as the most common postoperative negative behavioral changes. CONCLUSION Emergence delirium not only plays a role immediately after surgery but is also linked to early postoperative negative behavior within two weeks after outpatient adenoidectomy. Parents should be informed that early postoperative negative behavior may occur in 1 out of 4 patients if emergence delirium was present postoperatively. TRIAL REGISTRATION DRKS - German Clinical Trial Register ID: DRKS00013121.
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Affiliation(s)
- Anne Houben
- Klinikum Dortmund, Department of Anesthesiology and Operative Intensive Care Medicine, Dortmund, Germany
| | - Shahab Ghamari
- University Hospital Bonn, Department of Anesthesiology and Operative Intensive Care Medicine, Bonn, Germany
| | - Andreas Fischer
- ASG GbR Anesthesia and Pain Therapy, Moenchengladbach, Germany
| | - Claudia Neumann
- University Hospital Bonn, Department of Anesthesiology and Operative Intensive Care Medicine, Bonn, Germany
| | - Torsten Baehner
- St. Nikolaus-Stifts Hospital, Department of Anesthesiology and Operative Intensive Care Medicine, Andernach, Germany
| | - Richard K Ellerkmann
- Klinikum Dortmund, Department of Anesthesiology and Operative Intensive Care Medicine, Dortmund, Germany; University Hospital Bonn, Department of Anesthesiology and Operative Intensive Care Medicine, Bonn, Germany.
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Dexmedetomidine vs. total intravenous anaesthesia in paediatric emergence delirium: A network meta-analysis. Eur J Anaesthesiol 2021; 38:1111-1123. [PMID: 33720063 DOI: 10.1097/eja.0000000000001490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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).
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Abdeldayem O, Elsherbiny S. A comparison between the effects of propofol and sevoflurane in pediatric strabismus surgery on the quality and depth of anesthesia. Anesth Essays Res 2021; 15:257-262. [PMID: 35320953 PMCID: PMC8936868 DOI: 10.4103/aer.aer_93_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/30/2020] [Accepted: 11/19/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Strabismus surgery may be associated with several undesirable complications as increased incidence of the oculocardiac reflex (OCR), hemodynamic changes, emergency agitation (EA), postoperative pain, nausea, and vomiting. Previous studies suggested that deeper anesthesia monitored by bispectral index (BIS) protects against OCR. This study aims to evaluate the effect of the type of anesthesia on the quality of anesthesia in pediatric patients. Patients and Methods: One hundred American Society of Anesthesiologists physical status classes I and II pediatric patients, aged between 3 and 6 years old of both genders, who were subjected to strabismus surgery under general anesthesia were enrolled in this study. Patients were randomized into two equal groups (each = 50); in the first group, anesthesia was induced and maintained with sevoflurane (Group S), and in the second group, anesthesia was induced and maintained with propofol (Group P). Hemodynamics and BIS were monitored, and OCR and the need for atropine were recorded. Furthermore, EA using the Cravero scale was recorded. Results: The propofol group showed a higher incidence of OCR while the sevoflurane group had a higher incidence of postoperative agitation, pain, nausea, and vomiting, without statistically significant differences regarding hemodynamics. Conclusion: Although sevoflurane anesthesia may be superior to propofol in ameliorating OCR, it has been associated with an increased incidence of postoperative complications.
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Xu T, Kurth CD, Yuan I, Vutskits L, Zhu T. An approach to using pharmacokinetics and electroencephalography for propofol anesthesia for surgery in infants. Paediatr Anaesth 2020; 30:1299-1307. [PMID: 32965066 DOI: 10.1111/pan.14021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 02/05/2023]
Abstract
Safe and effective techniques for propofol total intravenous anesthesia (TIVA) in infants are not well imbedded into clinical practice, resulting in practitioner unfamiliarity and potential for over- and under-dosing. In this education article, we describe our approach to TIVA dosing in infants and toddlers (birth to 36 months) which combines the use of pharmacokinetic models with EEG multi-parameter analysis. Pharmacokinetic models describe propofol and remifentanil effect site concentrations (Ce) over time in different age groups for a given dosing regimen. These models display substantial biological variability between individuals within age groups, impeding their application to clinical practice. Nevertheless, they reveal that younger infants require a higher propofol loading dose, a lower propofol maintenance dose, and a higher remifentanil dose compared with older infants. Proprietary EEG indices (eg, Bispectral Index) can serve as a biomarker of propofol Ce in adults and children to guide dosing to the individual patient; however, they are not recommended for infants as their validity remains uncertain this population. In our experience, EEG waveforms and processed parameters can reflect propofol Ce in infants, reflected by spectral edge frequency (SEF), density spectral array (DSA), and waveform patterns. In our practice, we use a "lookup table" of age-based dosing regimens or target-controlled infusion (TCI) based on the pharmacokinetic models to deliver a target propofol Ce and co-administer remifentanil and/or regional technique for analgesia. We analyze Electroencephalogram (EEG) waveforms, SEF, and DSA to adjust the propofol dose or TCI target concentration to the individual infant. EEG analysis mitigates against biological variability inherent in the pharmacokinetic models and has improved our experience with TIVA for infants.
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Affiliation(s)
- Ting Xu
- Department of Anesthesiology and Department of Translational Neuroscience Center, West China Hospital, Sichuan University & The Research Units of West China (2018RU012) Chinese Academy of Medical Sciences, Chengdu, China.,Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Charles Dean Kurth
- Department of Anesthesiology and Critical Care Medicine and Neurology and Pediatrics, Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Tao Zhu
- Department of Anesthesiology and Department of Translational Neuroscience Center, West China Hospital, Sichuan University & The Research Units of West China (2018RU012) Chinese Academy of Medical Sciences, Chengdu, China
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Bagshaw O, McCormack J, Brooks P, Marriott D, Baxter A. The safety profile and effectiveness of propofol-remifentanil mixtures for total intravenous anesthesia in children. Paediatr Anaesth 2020; 30:1331-1339. [PMID: 32961621 DOI: 10.1111/pan.14018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/04/2020] [Accepted: 09/06/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Total intravenous anesthesia is used in less than 10% of operations in the UK. Many pediatric anesthetists in the UK and Ireland administer total intravenous anesthesia to children using a mixture of propofol and remifentanil in the same syringe. This unlicensed drug has not been studied clinically, because of lack of Medicines and Healthcare products Regulatory Agency (UK) or Food and Drug Administration (US) approval to undertake such studies. AIM The aim of this service evaluation was to assess the safety profile and effectiveness of propofol-remifentanil mixtures in the pediatric population undergoing a variety of surgical procedures. METHODS Pediatric Anesthetists in the UK and Ireland who regularly used propofol-remifentanil mixtures for total intravenous anesthesia were invited to submit data. This data were analyzed to assess the effectiveness of anesthesia and the incidence and nature of any complications that occurred. RESULTS Usable data were collected from 873 patients. Mixtures were most commonly administered in gastroenterology and ear, nose, and throat procedures. Two-thirds of patients were less than 10 years old, and their mean weight was 28.7 kg. Anesthesia using the mixture alone was successful in all but 3 patients. The commonest nonserious complication was coughing (4.6%), followed by movement (3.3%). The overall incidence of serious, related, unexpected adverse events requiring intervention was 1.7%. These included desaturation (5 patients), apnea (3), abdominal/chest rigidity (2), cough requiring paralysis (2), ventilatory problems (2), and hypotension (1). Most occurred at induction, were attributable to the properties of the drugs being administered and not directly related to the use of the mixture. No life-threatening adverse events were recorded. Complications were less common if a ≤5 μg mL-1 concentration of remifentanil was used. CONCLUSION These data demonstrate that effective anesthesia can be administered to pediatric patients undergoing a wide range of procedures using mixtures of propofol and remifentanil. Serious, related, unexpected adverse events requiring intervention had a low incidence and were largely due to predictable effects of the drugs being administered. A ≤5 μg mL-1 remifentanil concentration is associated with proportionately less complications.
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Affiliation(s)
- Oliver Bagshaw
- Department of Anaesthesia, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jon McCormack
- Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh, UK
| | - Peter Brooks
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
| | - David Marriott
- Department of Anaesthesia, Leicester Royal Infirmary, Leicester, UK
| | - Alistair Baxter
- Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh, UK
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Liu L, Liu C, Fang L. AMPK‑SIRT1 pathway dysfunction contributes to neuron apoptosis and cognitive impairment induced by sevoflurane. Mol Med Rep 2020; 23:56. [PMID: 33200801 PMCID: PMC7706003 DOI: 10.3892/mmr.2020.11694] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/05/2020] [Indexed: 02/07/2023] Open
Abstract
The anesthetic sevoflurane (Sev) is widely used because of its low blood-gas partition coefficient and lack of pungency. However, the application of Sevmay lead to cognitive impairment later in life. Previous results have indicated that exposure to Sev-induced neuronal apoptosis and cognitive dysfunction in a rat model, but much work remains to elucidate the mechanism. In the present study, inhibition in the AMP-activated protein kinase/Sirtuin 1 (AMPK/SIRT1) signaling pathway and a decrease in AMPK/SIRT1 activity was found to occur concomitantly in neuronal apoptosis induced by Sev. AICAR, an activator of AMPK, was able to suppress Sev-induced neuronal apoptosis and SIRT1 activity reduction in vitro. Further animal studies also showed that AICAR treatment blocked the deleterious cognition and AMPK/SIRT1 activity reduction in the cognition impairment rats induced by Sev. Taken together, it was concluded that the AMPK/SIRT1 signaling pathway mediates neuronal apoptosis and cognition impairment induced by Sev. The study provides evidence that AMPK activation ameliorates Sev-induced cognitive deficits.
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Affiliation(s)
- Liwei Liu
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, P.R. China
| | - Chao Liu
- Institute of Cardiovascular Diseases, Tianjin Chest Hospital, Tianjin 300457, P.R. China
| | - Lin Fang
- Department of Thyroid and Breast Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, P.R. China
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Using Guided Imagery to Relieve the Anxiety of Preschool Children Undergoing Dental Procedures. J Perianesth Nurs 2020; 36:18-23. [PMID: 32917508 DOI: 10.1016/j.jopan.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE Negative experiences in dental clinics can induce anxiety in patients, and the effects are particularly pronounced in children. When behavior guidance methods (eg, direct observation, tell-show-do, and ask-tell-ask) fail, general anesthesia is an important alternative; however, the procedure of anesthesia can also induce fear and anxiety. This study assessed the effectiveness of guided imagery in relieving the anxiety associated with dental surgery in children and caregivers. DESIGN A prospective randomized trial with two groups. METHODS The guided imagery in this study was meant to establish a rapport between the medical team and the patient, by encouraging the child to imagine having an adventure while riding in a spacecraft. Anxiety levels and behavior were measured using five well-established scales: the modified Yale Preoperative Scale-Short Form, the State-Trait Anxiety Inventory-6 items, the Watcha score, the Pediatric Anesthesia Emergent Delirium scale, and the Posthospitalization Behavioral Questionnaire-Ambulatory Surgery. FINDINGS The results indicate that the guided imagery had no significant effects on anxiety levels. CONCLUSIONS Guided imagery is a low-cost, easy-to-implement, interesting exercise capable of enhancing interactions between nursing staff and children. It may also help to condition children to the environment and thereby assist them in overcoming their fears.
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Hügel C, Chen J, Poznikoff AK, West NC, Reimer E, Görges M. Intravenous cannula placement in children for induction of general anesthesia: Prospective audit and identification of success factors. Paediatr Anaesth 2020; 30:874-884. [PMID: 32464692 DOI: 10.1111/pan.13936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/14/2020] [Accepted: 05/21/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Approaches to pediatric induction of anesthesia vary widely. While oral sedative premedication and inhalational induction are common, total intravenous anesthesia is becoming increasingly popular. Total intravenous anesthesia without anxiolytic premedication, which is the most commonly used technique in our hospital, requires intravenous (IV) cannula placement in an awake child. AIMS To quantify the success rate of IV cannula placement in 1 or 2 attempts and to identify success factors and barriers. METHODS With ethical approval and written informed consent from participating anesthesiologists, a prospective audit of IV cannulation was undertaken over a 1-month period. The attending anesthesiologist captured basic demographics, IV insertion characteristics, setting, distraction techniques, the behavior of the child, number of attempts, and success/failure. A logistic regression model for successful IV cannulation was created. Anesthesiologists and procedural suite nurses participated in semi-structured interviews to identify success factors, barriers, and teaching approaches. RESULTS Data from 984 cases were analyzed. IV induction was planned in 562 cases, and IV cannulation was successful in 90% of these patients. Anxiolytic premedication was given in 6% of cases. Observations indicated that 64% of children were pain- and reaction-free, and 90% experienced minimal or no reaction. Predictors for success included older child's age and child behavior at first encounter. Qualitative interview data from 13 participants suggested success factors included effective distraction, preparing the family for IV induction, parental presence, support of the operating room team, effective use of local analgesic cream, adapting the approach to the individual child, and the anesthesiologist's efficiency. Barriers included needle phobia, uncooperative child, anxious parents, ineffective use of analgesic cream, and unfavorable anatomy. Distraction techniques varied by age and developmental stage of the child. CONCLUSIONS Cannulation for planned IV induction is feasible for most children, enabling increased use of total intravenous anesthesia as an institutional anesthetic strategy.
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Affiliation(s)
- Celine Hügel
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada.,Department of Biomedical Engineering, Hamburg University of Applied Sciences, Hamburg, Germany
| | - James Chen
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (UBC), Vancouver, BC, Canada
| | - Andrew K Poznikoff
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (UBC), Vancouver, BC, Canada
| | - Nicholas C West
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (UBC), Vancouver, BC, Canada
| | - Eleanor Reimer
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada.,Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (UBC), Vancouver, BC, Canada
| | - Matthias Görges
- Research Institute, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia (UBC), Vancouver, BC, Canada
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Urits I, Peck J, Giacomazzi S, Patel R, Wolf J, Mathew D, Schwartz R, Kassem H, Urman RD, Kaye AD, Viswanath O. Emergence Delirium in Perioperative Pediatric Care: A Review of Current Evidence and New Directions. Adv Ther 2020; 37:1897-1909. [PMID: 32274749 DOI: 10.1007/s12325-020-01317-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Jacquelin Peck
- Department of Anesthesiology, Mount Sinai Medical Center, Miami, FL, USA
| | - Stephen Giacomazzi
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Riki Patel
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - John Wolf
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Denzil Mathew
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Ruben Schwartz
- Department of Anesthesiology, Mount Sinai Medical Center, Miami, FL, USA
| | - Hisham Kassem
- Department of Anesthesiology, Mount Sinai Medical Center, Miami, FL, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Simonsen BY, Skovby P, Lisby M. An evaluation of the Danish version of the Pediatric Anesthesia Emergence Delirium scale. Acta Anaesthesiol Scand 2020; 64:613-619. [PMID: 31886528 DOI: 10.1111/aas.13543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/11/2019] [Accepted: 12/20/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Emergence Delirium (ED) is a common complication from anesthesia. Although ED has a short duration, detection is important due to the risk that ED poses for post-operative complications in the child. The Pediatric Anesthesia Emergence Delirium (PAED) scale has been translated into Danish, but it has not yet been validated. The aim of this study was to investigate the inter-rater reliability, criterion validity, and responsiveness of the Danish version of the PAED scale as well as to determine the prevalence of ED. METHOD A sample of 100 post-operative children were enrolled and assessed with the PAED scale at pre-specified time intervals. Inter-rater reliability was assessed independently by 2 raters. For criterion validity, a clinical expert was chosen as the gold standard. Sensitivity and specificity were based on a comparison between the scoring of the raters and the gold standard. Responsiveness was assessed by comparing changes in scores. Prevalence was based on the PAED scale's cut-off level of ≥10 points. RESULTS A high level of agreement was found, with an intraclass correlation coefficient of 0.85-0.94. Few outliers appeared in the Bland-Altman plot. Sensitivity ranged from 70% to 86%, and the specificity of both raters against the gold standard was 100%. Changes in scores were indicative of responsiveness. Prevalence was 13.2%. CONCLUSION The Danish version of the PAED scale was found reliable and demonstrated high levels of sensitivity and specificity. In addition, it was possible to identify changes in scores over time. Prevalence was in line with existing literature.
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Affiliation(s)
| | - Pernille Skovby
- Department of Pediatrics Regional Hospital Unit West Jutland Herning Hospital Herning Denmark
| | - Marianne Lisby
- Research Centre of Emergency Medicine Aarhus University Hospital Aarhus Denmark
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Devroe S, Devriese L, Debuck F, Fieuws S, Cools B, Gewillig M, Van de Velde M, Rex S. Effect of xenon and dexmedetomidine as adjuncts for general anesthesia on postoperative emergence delirium after elective cardiac catheterization in children: study protocol for a randomized, controlled, pilot trial. Trials 2020; 21:310. [PMID: 32245513 PMCID: PMC7126401 DOI: 10.1186/s13063-020-4231-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/04/2020] [Indexed: 12/29/2022] Open
Abstract
Background Emergence delirium, a manifestation of acute postoperative brain dysfunction, is frequently observed after pediatric anesthesia and has been associated with the use of sevoflurane. Both xenon and dexmedetomidine possess numerous desirable properties for the anesthesia of children with congenital heart disease, including hemodynamic stability, lack of neurotoxicity, and a reduced incidence of emergence delirium. Combining both drugs has never been studied as a balanced-anesthesia technique. This combination allows the provision of anesthesia without administering anesthetic drugs against which the Food and Drug Administration (FDA) issued a warning for the use in young children. Methods/Design In this phase-II, mono-center, prospective, single-blinded, randomized, controlled pilot trial, we will include a total of 80 children aged 0–3 years suffering from congenital heart disease and undergoing general anesthesia for elective diagnostic and/or interventional cardiac catheterization. Patients are randomized into two study groups, receiving either a combination of xenon and dexmedetomidine or mono-anesthesia with sevoflurane for the maintenance of anesthesia. The purpose of this study is to estimate the effect size for xenon-dexmedetomidine versus sevoflurane anesthesia with respect to the incidence of emergence delirium in children. We will also describe group differences for a variety of secondary outcome parameters including peri-interventional hemodynamics, emergence characteristics, incidence of postoperative vomiting, and the feasibility of a combined xenon-dexmedetomidine anesthesia in children. Discussion Sevoflurane is the most frequently used anesthetic in young children, but has been indicated as an independent risk factor in the development of emergence delirium. Xenon and dexmedetomidine have both been associated with a reduction in the incidence of emergence delirium. Combining xenon and dexmedetomidine has never been described as a balanced-anesthesia technique in children. Our pilot study will therefore deliver important data required for future prospective clinical trials. Trial registration EudraCT, 2018–002258-56. Registered on 20 August 2018. https://www.clinicaltrialsregister.eu.
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Affiliation(s)
- Sarah Devroe
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Pediatric and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium.
| | - Lisa Devriese
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Frederik Debuck
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Steffen Fieuws
- I-Biostat, KU Leuven - University of Leuven, Leuven, Belgium
| | - Bjorn Cools
- Department of Pediatric and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Pediatric and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
| | - Marc Van de Velde
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Cardiovascular Sciences, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Cardiovascular Sciences, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
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Lee SJ, Sung TY. Emergence agitation: current knowledge and unresolved questions. Korean J Anesthesiol 2020; 73:471-485. [PMID: 32209961 PMCID: PMC7714637 DOI: 10.4097/kja.20097] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
Emergence agitation (EA), also referred to as emergence delirium, can have clinically significant consequences. The mechanism of EA remains unclear. The proposed risk factors of EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preoperative or intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce its adverse consequences. Several tools are available for assessing EA. However, there are no standardized clinical research practice guidelines and its incidence varies considerably with the assessment tool or definition used. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may help in preventing of EA. However, it is difficult to identify patients at high risk and apply preventive measures in various clinical situations. The risk factors and outcomes of preventive strategies vary with the methodologies of studies and patients assessed.This review discusses important outcomes of research on EA and directions for future research.
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Affiliation(s)
- Seok-Jin Lee
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Tae-Yun Sung
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Lauder GR, Thomas M, von Ungern-Sternberg BS, Engelhardt T. Volatiles or TIVA: Which is the standard of care for pediatric airway procedures? A pro-con discussion. Paediatr Anaesth 2020; 30:209-220. [PMID: 31886922 DOI: 10.1111/pan.13809] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 12/21/2022]
Abstract
Anesthesia for pediatric airway procedures constitutes a true art form that requires training and experience. Communication between anesthetist and surgeon to establish procedure goals is essential in determining the most appropriate anesthetic management. But does the mode of anesthesia have an impact? Traditionally, inhalational anesthesia was the most common anesthesia technique used during airway surgery. Introduction of agents used for total intravenous anesthesia (TIVA) such as propofol, short-acting opioids, midazolam, and dexmedetomidine has driven change in practice. Ongoing debates abound as to the advantages and disadvantages of volatile-based anesthesia versus TIVA. This pro-con discussion examines both volatiles and TIVA, from the perspective of effectiveness, safety, cost, and environmental impact, in an endeavor to justify which technique is the best specifically for pediatric airway procedures.
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Affiliation(s)
- Gillian R Lauder
- Department of Anesthesia, BC Children's Hospital, Vancouver, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Mark Thomas
- Department of Anaesthesia, Great Ormond St Hospital, London, UK
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Australia.,Medical School, The University of Western Australia, Perth, Australia.,Telethon Kids Institute, Perth, Australia
| | - Thomas Engelhardt
- Department of Anesthesia, McGill University Health Centre, Montreal Children's Hospital, Montreal, QC, Canada
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Effects of intravenous and mask induction on post-operative emergence delirium in pediatric patients undergoing tonsillectomy with or without adenoidectomy. Ir J Med Sci 2020; 189:1061-1068. [PMID: 32048203 DOI: 10.1007/s11845-020-02197-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/05/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Emergence delirium occurs in children during recovery from general anesthesia. The aim of the study was to examine the effects of mask and intravenous sevoflurane anesthesia induction on emergence delirium in children undergoing tonsillectomy with or without adenoidectomy. METHODS This single-blinded, prospective, randomized clinical trial was conducted in the operating room and the post-operative recovery area at a university hospital. Sixty-seven children (aged 3-12 years) were randomly assigned to receive either mask induction (group M) or intravenous induction (group IV). Vascular access was provided in group M after 8% sevoflurane and 60% nitrous oxide in oxygen were given through a mask. In the IV cohort, an intravenous cannula was inserted prior to induction. The incidence of emergence delirium was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale after arrival in the post-anesthesia care unit. Post-operative pain was assessed using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. RESULTS PAED scores were significantly higher in group M at 5 min (group M = 12.2 ± 4.215, group IV = 9.1 ± 4.0; mean difference = 3.094, 95% CI [1.108; 5.081]; P = 0.003), at 15 min (group M = 8.0 ± 2.6, group IV = 5.1 ± 2.3; mean difference = 2.942, 95% CI [1.586-4.301]; P < 0.001), and at 30 min (group M = 5.1 ± 2.8, group IV = 2.5 ± 1.8; mean difference = 2.620, 95% CI [1.457; 3.783]; P < 0.001) than in group IV. The FLACC scale scores were similar between the two groups. CONCLUSION Mask induction for pediatric patients undergoing tonsillectomy with or without adenoidectomy increased Pediatric Anesthesia Emergence Delirium scores more than intravenous induction. TRIAL REGISTRATION NCT03252405.
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West N, Christopher N, Stratton K, Görges M, Brown Z. Reducing preoperative anxiety with Child Life preparation prior to intravenous induction of anesthesia: A randomized controlled trial. Paediatr Anaesth 2020; 30:168-180. [PMID: 31869478 DOI: 10.1111/pan.13802] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/03/2019] [Accepted: 12/18/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Induction of anesthesia can be stressful: Up to 60% of children suffer significant anxiety immediately before surgery. Anxiety is associated with higher postoperative analgesia requirements, higher incidence of emergence delirium, and detrimental effects on sleep and behavior. Child Life preparation includes role-play, expectation-setting, and teaching coping strategies. AIM : The aim of this trial was to determine whether preoperative Child Life preparation reduces anxiety prior to intravenous induction of anesthesia. METHODS Children aged 3-10 years, with no known preexisting anxiety and no preoperative anxiolytics, undergoing elective day surgery lasting ≤ 2 hours, were enrolled in a randomized controlled trial. Each child's baseline anxiety was assessed in the anesthetic care unit, using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF, observational scores from 22.9, minimal anxiety, to 100, maximal anxiety) as the primary outcome. The child was randomly assigned to intervention (minimum 15 minutes Child Life preparation) or control (standard practice without Child Life preparation). Participants entered the operating room with one parent. A researcher (blinded to group allocation) scored the child's operating room anxiety using mYPAS-SF, up to the first attempt at intravenous cannulation. RESULTS Fifty-nine children completed the study, aged median [interquartile range] 5 [3-7] years. Baseline mYPAS-SF anxiety was 29.2 [22.9-37.5] for all children, and operating room anxiety was 29.2 [22.9-49.0]. Operating room anxiety was higher than baseline in 16/31 (52%) children in the control group and 6/28 (21%) in the Child Life preparation group. ANCOVA revealed a significant effect of baseline mYPAS-SF anxiety and group on operating room anxiety (F = 10.31, P < .001, adjusted R2 = .24); individual parameter estimates indicated that Child Life preparation reduced operating room anxiety by 13.8 (95% CI 4.4-23.1) points compared to control, P = .005. CONCLUSION A brief, targeted Child Life preparation session had a statistically significant effect on reducing preoperative anxiety prior to intravenous induction of anesthesia in young children, with no known preexisting anxiety. This effect may be clinically important and suggests that Child Life can be a valuable component of pediatric surgical care. Further research is required in specific populations.
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Affiliation(s)
- Nicholas West
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Nancy Christopher
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Kirsten Stratton
- Child Life Department, BC Children's Hospital, Vancouver, BC, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Zoë Brown
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Anesthesia Department, BC Children's Hospital, Vancouver, BC, Canada
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Dervan LA, Di Gennaro JL, Farris RWD, Watson RS. Delirium in a Tertiary PICU: Risk Factors and Outcomes. Pediatr Crit Care Med 2020; 21:21-32. [PMID: 31568239 DOI: 10.1097/pcc.0000000000002126] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine risk factors and outcomes associated with delirium in PICU patients. DESIGN Retrospective cohort study. SETTING Thirty-two-bed PICU within a tertiary care academic children's hospital. PATIENTS All children admitted to the PICU March 1, 2014, to October 1, 2016, with at least one Cornell Assessment of Pediatric Delirium score (n = 2,446). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cornell Assessment of Pediatric Delirium score was performed twice daily as standard of care. We characterized delirium as: 1) presence of greater than or equal to 1 positive score (Cornell Assessment of Pediatric Delirium ≥ 9) and 2) number of days with a positive score. We built multivariable logistic and linear regression models using electronic medical records data. Many patients (n = 1,538; 63%) had a short length of stay (< 48 hr). Compared with patients with length of stay greater than or equal to 48 hours, fewer experienced delirium (30% vs 69%; p < 0.0001). Among 908 patients with length of stay greater than or equal to 48 hours, presence of delirium was independently associated with age less than 2 years old, baseline cognitive dysfunction, primary diagnosis, and duration of mechanical ventilation. Benzodiazepines demonstrated a dose-response effect (odds ratio for presence of delirium, 1.8 [p = 0.03], 3.4 [p < 0.001], and 9.7 [p = 0.005] for < 25th percentile, 25-75th percentile, and > 75th percentile of total dose, vs no exposure). In terms of outcomes, presence of delirium was independently associated with increased ICU length of stay (p < 0.001), whereas days of delirium were independently associated with decline in cognitive function from ICU admission to discharge (odds ratio, 1.06; p < 0.001), increased ICU (p < 0.001), and hospital length of stay (p < 0.001). Neither delirium presence nor total days were independently associated with mortality. CONCLUSIONS Delirium is common in the PICU, particularly among patients with length of stay greater than or equal to 48 hours. It is independently associated with patient characteristics and PICU exposures, including benzodiazepines. The role of delirium as an independent causal factor in patient outcome requires further investigation.
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Affiliation(s)
- Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Jane L Di Gennaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Reid W D Farris
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA
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Ng KT, Sarode D, Lai YS, Teoh WY, Wang CY. The effect of ketamine on emergence agitation in children: A systematic review and meta-analysis. Paediatr Anaesth 2019; 29:1163-1172. [PMID: 31587414 DOI: 10.1111/pan.13752] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Ketamine is believed to reduce the incidence of emergence agitation in children undergoing surgery or procedure. However, recent randomized controlled trials reported conflicting findings. AIMS To investigate the effect of ketamine on emergence agitation in children. METHODS Databases of MEDLINE, EMBASE, and CENTRAL were systematically searched from their start date until February 2019. Randomized controlled trials comparing intravenous ketamine and placebo in children were sought. The primary outcome was the incidence of emergence agitation. Secondary outcomes included postoperative pain score, duration of discharge time, and the adverse effects associated with the use of ketamine, namely postoperative nausea and vomiting, desaturation, and laryngospasm. RESULTS Thirteen studies (1125 patients) were included in the quantitative meta-analysis. The incidence of emergence agitation was 14.7% in the ketamine group and 33.3% in the placebo group. Children receiving ketamine had a lower incidence of emergence agitation, with an odds ratio being 0.23 (95% confidence interval: 0.11 to 0.46), certainty of evidence: low. In comparison with the placebo, ketamine group achieved a lower postoperative pain score (odds ratio: -2.42, 95% confidence interval: -4.23 to -0.62, certainty of evidence: very low) and lower pediatric anesthesia emergence delirium scale at 5 minutes after operation (odds ratio: -3.99, 95% confidence interval: -5.03 to -2.95; certainty of evidence: moderate). However, no evidence was observed in terms of incidence of postoperative nausea and vomiting, desaturation, and laryngospasm. CONCLUSION In this meta-analysis of 13 randomized controlled trials, high degree of heterogeneity and low certainty of evidence limit the recommendations of ketamine for the prevention of emergence agitation in children undergoing surgery or imaging procedures. However, the use of ketamine is well-tolerated without any notable adverse effects across all the included trials. PROSPERO REGISTRATION CRD42019131865.
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Affiliation(s)
- Ka Ting Ng
- Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Deep Sarode
- Department of Anaesthesiology, University of Glasgow, Glasgow, Scotland
| | - Yuen Sin Lai
- Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Wan Yi Teoh
- Department of Anaesthesiology, University of Liverpool, Liverpool, UK
| | - Chew Yin Wang
- Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia
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Tang Y, Meng J, Zhang X, Li J, Zhou Q. Comparison of dexmedetomidine with propofol as sedatives for pediatric patients undergoing magnetic resonance imaging: A meta-analysis of randomized controlled trials with trial sequential analysis. Exp Ther Med 2019; 18:1775-1785. [PMID: 31410137 PMCID: PMC6676186 DOI: 10.3892/etm.2019.7751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/23/2019] [Indexed: 11/10/2022] Open
Abstract
Dexmedetomidine and propofol are commonly used sedative agents in pediatric patients undergoing magnetic resonance imaging (MRI). The present meta-analysis aimed to compare dexmedetomidine with propofol in pediatric patients undergoing MRI using trial sequential analysis (TSA). The PubMed, Cochrane Library and Web of Knowledge databases were systematically searched for entries up to August 2018 for potential randomized controlled trials comparing dexmedetomidine with propofol in pediatric patients undergoing MRI. Data were extracted by two independent authors and analyzed using Revman version 5.2 software. Six trials involving 415 pediatric patients were included in the final analysis. A shorter recovery time (P<0.01) and onset time of sedation were identified for propofol compared with dexmedetomidine (P<0.01); however, there were no significant differences in the duration of sedation (P=0.37). Furthermore, pediatric patients receiving propofol were discharged sooner than those receiving dexmedetomidine (P=0.02). The incidence of failed sedation did not significantly differ between the two groups (P=0.81). Propofol induced a lower incidence of 5-min (P=0.03) and 10-min Pediatric Anesthesia Emergence Delirium (P<0.01), but a higher incidence of desaturation (P<0.01). The duration of MRI was similar between the two groups (P=0.15). TSA indicated that the monitoring boundary was crossed by the cumulative z curve, providing supportive evidence for the shorter recovery time in the propofol group. Propofol is recommended for pediatric sedation during MRI, owing to shorter recovery time and onset of sedation time, as well as a faster discharge from hospital, and a lower incidence of PAED score >10, compared with dexmedetomidine. However, considering the possibility of desaturation, propofol should be used with caution.
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Affiliation(s)
- Yong Tang
- Department of Radiology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Juan Meng
- Operating Room, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Xinxian Zhang
- Department of Radiology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Jiong Li
- Department of Radiology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Qiang Zhou
- Department of Radiology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
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Kawai M, Kurata S, Sanuki T, Mishima G, Kiriishi K, Watanabe T, Ozaki-Honda Y, Yoshida M, Okayasu I, Ayuse T, Tanoue N, Ayuse T. The effect of midazolam administration for the prevention of emergence agitation in pediatric patients with extreme fear and non-cooperation undergoing dental treatment under sevoflurane anesthesia, a double-blind, randomized study. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:1729-1737. [PMID: 31190751 PMCID: PMC6529617 DOI: 10.2147/dddt.s198123] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/19/2019] [Indexed: 12/11/2022]
Abstract
Background: Sevoflurane is generally the preferred anesthetic agent for general anesthesia in pediatric patients, due to its rapid induction and recovery characteristics. However, it has been recognized that a major complication is emergence agitation when awakening from general anesthesia. The aim of this study was to evaluate the occurrence rate of emergence agitation in the operating room and postoperative recovery area following intraoperative administration of midazolam to pediatric patients under general anesthesia. Patients and methods: One hundred and twenty pediatric patients undergoing dental treatment under sevoflurane anesthesia were enrolled in this study. The patients were divided into three groups (n=40 each in the 0.1 mg/kg midazolam, 0.05 mg/kg midazolam, and control with saline groups). Midazolam or saline was injected intravenously approximately 30 minutes before the end of the dental treatment. We used the Richmond Agitation and Sedation Scale (RASS) to assess the level of sedation and drowsiness at emergence phase in the operating room. We also used the Pediatric Anesthesia Emergence Delirium Scale (PAED) to assess the level of agitation and delirium at the full recovery phase from anesthesia in the recovery area. Results: At the emergence phase, the incidence of emergence agitation in the 0.1 mg/kg midazolam group was significantly lower than in the other groups (p=0.0010). At the recovery phase, there was no significant difference among the three groups. The odds ratio between PAED score and RASS score was 4.0 using logistic regression analysis. The odds ratio between PAED score and Disability was 2.5. Conclusion: Administration of a single dose of 0.1 mg/kg midazolam dose significantly decreases the incidence of severe emergence agitation at the emergence after sevoflurane anesthesia, but not at the recovery phase. Furthermore, the evaluation of sedative and agitation condition using RASS score at emergence from anesthesia is useful to predict occurrence of agitation in the recovery phase.
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Affiliation(s)
- Mari Kawai
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinji Kurata
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Takuro Sanuki
- Nagasaki University Institute of Biomedical Sciences, Course of Medical and Dental Sciences, Dental Anesthesiology, Nagasaki, Japan
| | - Gaku Mishima
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Kensuke Kiriishi
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Toshihiro Watanabe
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Yu Ozaki-Honda
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Mizuki Yoshida
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Ichiro Okayasu
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan
| | - Terumi Ayuse
- Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, Japan
| | - Naomi Tanoue
- Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, Japan
| | - Takao Ayuse
- Department of Dental Anesthesia, Nagasaki University Hospital, Nagasaki, Japan.,Nagasaki University Institute of Biomedical Sciences, Course of Medical and Dental Sciences, Dental Anesthesiology, Nagasaki, Japan.,Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, Japan
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Doerrfuss JI, Kramer S, Tafelski S, Spies CD, Wernecke KD, Nachtigall I. Frequency, predictive factors and therapy of emergence delirium: data from a large observational clinical trial in a broad spectrum of postoperative pediatric patients. Minerva Anestesiol 2019; 85:617-624. [DOI: 10.23736/s0375-9393.19.13038-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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