Cause analysis, prevention, and treatment of postoperative restlessness after general anesthesia in children with cleft palate

Analysis of contributing factors and nursing interventions for postoperative agitation following general anesthesia in thoracotomy patients

To analyze the factors influencing agitation during emergence from general anesthesia in patients undergoing thoracotomy and to explore corresponding nursing interventions to optimize the postoperative recovery process. This study included 200 patients who underwent thoracotomy with general anesthesia at our hospital between January 12, 2022, and June 1, 2023. After surgery, all patients were closely monitored in the Intensive Care Unit (ICU). Based on their agitation status during emergence from anesthesia, patients were divided into 2 groups: an observation group (87 cases with agitation) and a control group (113 cases without agitation). We performed univariate analysis and multivariate logistic regression to identify risk factors for agitation. Based on these findings, we proposed targeted nursing strategies to address the causes of agitation, prevent complications, and meet patient care needs. Univariate analysis showed significant differences between the observation and control groups regarding age, propofol dosage, duration of surgery, infusion volume, and preoperative cognitive dysfunction (P < .05). Multivariate logistic regression identified 3 key risk factors: age over 60 years, surgery duration over 2 hours, and preoperative cognitive dysfunction. Based on these findings, we developed targeted nursing strategies to reduce the incidence of agitation and promote smooth recovery. Agitation during emergence from general anesthesia in patients undergoing thoracotomy is closely related to factors such as age and surgery duration. Developing personalized nursing plans based on these factors can enhance postoperative monitoring and care, thereby reducing agitation and improving recovery quality.

Enhanced recovery after cleft palate repair: A quality improvement project

BACKGROUND

Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery.

AIMS

The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery.

METHODS

A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts.

RESULTS

Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p < .0001) relative to our historical cohort (n = 63), with a mean difference of -0.33 ± 0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p = .002), with a mean difference of -0.27 ± 0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p = .02) relative to our historical cohort, with a mean difference of -3.81 ± 1.56 h (95% CI -6.9 to -0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes.

CONCLUSION

Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.

Urethane Improves the Response of Auditory Neurons to Tone

Urethane has little effect on nervous system and is often used in neuroscience studies. However, the effect of urethane in neurons is not thoroughly clear. In this study, we investigated changes in neuron responses to tones in inferior colliculus during urethane anesthesia. As urethane was metabolized, the best and characteristic frequencies did not obviously change, but the minimal threshold (MT) remained relatively stable or was elevated. The frequency tuning bandwidth at 60 dB SPL (BW_60dBSPL) remained unchanged or decreased, and the average evoked spike of effective frequencies at 60 dB SPL (ES_60dBSPL) gradually decreased. Although the average evoked spike of effective frequencies at a tone intensity of 20 dB SPL above MT (ES_{20dBSPLaboveMT}) decreased, the frequency tuning bandwidth at a tone intensity of 20 dB SPL above MT (BW_{20dBSPLaboveMT}) did not change. In addition, the changes in MT, ES_60dBSPL, BW_60dBSPL, and ES_{20dBSPLaboveMT} increased with the MT in pre-anesthesia awake state (MT_{pre−anesthesiaawake}). In some neurons, the MT was lower, BW_60dBSPL was broader, and ES_60dBSPL and ES_{20dBSPLaboveMT} were higher in urethane anesthesia state than in pre-anesthesia awake state. During anesthesia, the inhibitory effect of urethane reduced the ES_{20dBSPLaboveMT}, but did not change the MT, characteristic frequency, or BW_{20dBSPLaboveMT}. In the recording session with the strongest neuron response, the first spike latency did not decrease, and the spontaneous spike did not increase. Therefore, we conclude that urethane can reduce/not change the MT, increase the evoked spike, or broaden/not change the frequency tuning range, and eventually improve the response of auditory neurons to tone with or without “pushing down” the tonal receptive field in thresholding model. The improved effect increases with the MT_{pre−anesthesiaawake} of neurons. The changes induced by the inhibitory and improved effects of urethane abide by similar regularities, but the change directions are contrary. The improvement mechanism may be likely due to the increase in the ratio of excitatory/inhibitory postsynaptic inputs to neurons.

A Comparison of Dexmedetomidine and Propofol on Emergence Delirium in Children Undergoing Cleft Palate Surgery With Sevoflurane-Based Anesthesia

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.

Effect of different routes of administration on early cognitive function following inguinal hernia repair

PURPOSE

To analyze the effects of different routes of dexmedetomidine administration on early cognitive function following inguinal hernia repair.

METHODS

A total of 83 patients with pediatric inguinal hernias admitted to our hospital from January 2018 to October 2020 were divided into control group (CNG, n = 41) and observation group (OG, n = 42) by random number table. The OG was given 2 μg/kg of dexmedetomidine hydrochloride by intranasal administration, and the CNG was treated with 0.5 μg/kg of dexmedetomidine hydrochloride via intravenous (IV) infusion pump. The hemodynamics, condition of anesthesia, awakening, and safety were compared between the two groups.

RESULTS

Systolic blood pressure and oxygen saturation levels at T1 and T2 in the OG were not different from those in the CNG (P > 0.05), and heart rates in the OG were all higher than those in the CNG (P < 0.05). The incidence of emergence agitation during awakening was 4.76% in the OG, which was lower than 21.95% compared with the CNG (P < 0.05). Ramsay sedation scores at 15 and 30 min after awakening in the OG were higher than those in the CNG, and PAED scores in the OG were lower than those in the CNG (P < 0.05). Cognitive, language, and motor scores in the OG were higher than those in the CNG at 3 days after surgery (P < 0.05), and the incidence of cognitive dysfunction was 4.76% in the OG at 3 days after surgery, which was lower compared with 21.95% in the CNG (P < 0.05).

CONCLUSION

Application of dexmedetomidine hydrochloride by intranasal administration or intravenous infusion before induction can ensure rapid postoperative awakening of the children without causing significant fluctuations in blood pressure and oxygen saturation, and both methods have a high safety profile. However, intranasal administration results in more satisfactory sedation, less postoperative agitation upon awakening, and reduces postoperative cognitive dysfunction.

Postoperative complications in Chinese children following dental general anesthesia: A cross-sectional study

Dental general anesthesia (DGA) is a safe and high-quality restorative and preventive treatment option for children with severe early childhood caries (S-ECC), who require extensive dental treatment and exhibit anxiety and emotional or cognitive immaturity or are medically compromised. However, several postoperative complications have been reported in children under DGA. This study aimed to evaluate and analyze the prevalence of the relevant factors of postoperative complications in healthy Chinese children following DGA to provide a foundation for pre-, intra-, and postoperative overall health management for healthy and disabled children after DGA.A total of 369 systematically healthy Chinese children (36-71 months old) undergoing a DGA were studied. Data were collected on patients' histories, characteristics, anesthesia, and dental procedures. Parents or caregivers were interviewed before and 72 hours after the procedure. Data were analyzed using logistic regression.Approximately 94.86% of the enrolled children reported one or more complications. The most prevalent complication was postoperative pain (62.70%), followed by weariness, agitation, masticatory problems, drowsiness, oral bleeding, coughing, fever, sore throat, nausea, constipation, epistaxis, vomiting, excitement, and diarrhea. The long duration of the operation was a risk factor for postoperative pain and weariness. A high nutritional status could be a protective factor for postoperative fever.Prolonged operation means complex treatment, such as pulp therapy or extraction. We speculate that the longer the duration is, the more difficult the dental procedures are. The accumulation of discomfort leads to pain. We suspect that children in lower nutritional levels are more likely to suffer from bacteremia or dehydration, resulting in fever.Postoperative pain was the most prevalent complication after the DGA. A decrease in dental procedure duration might reduce the odds of postoperative pain and weariness. A high nutritional status could be a protective factor for postoperative fever. Children with low nutritional status could be more susceptible to postoperative fever.

[Investigation of postoperative complications in children after dental therapy under general anesthesia]

OBJECTIVE

This study aimed to evaluate the postoperative complications undergoing dental general anesthesia in children and analyze the prevalence and related factors.

METHODS

This prospective study involved 292 systematically healthy children (36 to 71 months old) who received extensive dental treatment under general anesthesia. Data about patients' histories, characteristics, dental and anesthesia procedure were collected. Parents or caregivers were interviewed face to face preoperation and 72 h postoperation. Data were analyzed using logistic regression.

RESULTS

Approximately 93.5% of the enrolled children reported one or more complications. The most prevalent complication was postoperative pain, followed by weariness, agitation, problem in eating, drowsiness, oral bleeding, cough, fever, etc. The length of operative time and femininity were the risks of the postoperative pain. Nutrition status was the factor probably in association with fever.

CONCLUSIONS

The children receive longer operative time and girls show to be more susceptible to the postoperative pain. High nutrition status could be the protective factor of postoperative fever.