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

Analysis of Adverse Events in the Postanesthesia Unit at a Tertiary Pediatric Hospital

PURPOSE

The postanesthesia care unit (PACU) is an indispensable part of modern medicine which provides critical care to patients to ensure safe and smooth emergence from anesthesia. The adverse events in the PACU have been widely investigated in adults. However, little is known about the adverse events in pediatric populations. This study was designed to investigate adverse events, including the incidence, disease spectrum, and possible risk factors, in pediatric patients in the PACU at a tertiary pediatric hospital.

DESIGN

This is a retrospective observational study.

METHODS

Children admitted to the PACU at the Children's Hospital of Fudan University from September 2021 to August 2022 were included in the study. The following adverse events were recorded: hypothermia, fever, adverse airway events, hypotension, hypertension, prolonged length of stay in PACU, pain, reintubation, neurological events, unplanned admission to the intensive care unit, arrhythmia, water-electrolyte imbalance, and bleeding requiring medical intervention. Descriptive analyses, t tests, and χ2 tests were performed.

FINDINGS

A total of 16,012 children were included in the study, and 305 adverse events occurred in 237 (1.48%) children. The three most frequently occurring adverse events were prolonged stay in the PACU (8.4%), adverse airway events (5.6%), and abnormal temperature (2.7%). Age, American Society of Anesthesiologists' grade, and general surgery were independent risk factors of both overall adverse events and prolonged stay in the PACU in multivariate logistic regression analysis. Children with adverse events stayed in the PACU significantly longer than those without adverse events (60.04 ± 1.01 vs 95.8 ± 47.25 minutes, P < .05). Compared with the other surgeries, a significantly higher proportion of severe pain (37.5% vs 0%) after thoracic surgery, prolonged stay in the PACU (52.9% vs 36.4%) after general surgery, and neurological events (14.7% vs 0%) after neurological surgery was detected, while a significantly lower proportion of adverse airway events after general surgery (21.1% vs 43%) and neurological surgery (8.8% vs 43%) was detected, respectively.

CONCLUSIONS

Our study reports the current incidence and spectrum of adverse events in the PACU at a tertiary pediatric hospital. Patients with young age, high American Society of Anesthesiologists' grade, and those from the general surgery department are at a significantly increased risk of adverse events in the PACU. Significant differences were detected in the proportion of specific adverse events after specific surgeries.

Effects of prophylactic nalbuphine on emergence agitation and postoperative pain in pediatric patients undergoing ENT surgery with sevoflurane anesthesia

Background

Emergence agitation (EA) is a common complication in the pediatric population. This study aimed to investigate the effect of the prophylactic nalbuphine on EA in pediatric patients receiving sevoflurane anesthesia.

Methods

The children undergoing ear, nose, and throat (ENT) surgery were administered 0.2 mg/kg nalbuphine (the nalbuphine group) or the same volume of normal saline (the control group) 5 min before the end of the surgery. The extubating time, time to eye-opening and duration of the post-anesthesia care unit (PACU) were recorded. Heart rate and blood pressure were monitored before and 5 min after nalbuphine administration. Pain was assessed using Face Legs Activity Cry and Consolability (FLACC) scales, and the drug-related postoperative complications (e.g., EA, delayed awakening, nausea and vomiting, and respiratory depression) were recorded.

Results

One-hundred and thirty pediatric patients were randomly divided into nalbuphine and control groups (n = 65). The nalbuphine group showed a significantly lower incidence of EA than the control group (20% vs. 46.2%, P = 0.002). No significant differences between the two groups were observed in heart rate and blood pressure 5 min after nalbuphine administration (P > 0.05). No significant differences were observed between the two groups regarding extubating time, time to eye-opening, and duration of PACU. The FLACC scales demonstrated lower values in the nalbuphine group than in the control group during the initial 4 h after the surgery. However, the FLACC scales showed similar values between 5 and 12 h after the surgery.

Conclusions

In summary, the results of this study demonstrated that prophylactic natbuphine could minimize the incidence of EA in pediatric patients following ENT surgery without increasing the extubating time and PACU duration.

Clinical Trial Registration

http://www.chictr.org.cn, identifier [ChiCTR2300070046].

Research trends related to emergence agitation in the post-anaesthesia care unit from 2001 to 2023: A bibliometric analysis

Background

Emergence agitation (EA) is a behavioural disturbance encountered during the recovery phase of patients following general anaesthesia. It is characterised by restlessness, involuntary limb movements, and drainage tube withdrawal and may significantly harm patients and medical staff. The mechanism of EA has not been fully understood and is still a challenging subject for researchers.

Methods

We extracted relevant publications published between 1 January 2001 and 31 December 2023 on the Web of Science Core Collection platform. VOSviewer software was utilised to analyse the retrieved literature and predict the development trends and hotspots in the field.

Results

The results show that the number of publications grew annually, with China contributing the most, followed by the United States and South Korea. The co-occurrence of keywords "children," "propofol," "risk factors" are current research hotspots. Owing to its self-limiting and short-duration characteristics, EA lacks standardised clinical time guidelines and objective assessment tools, which may be the focus of future research in this field.

Conclusions

Understanding the research hotspots and the latest progress in this field, this study will help to continuously improve the clinical understanding and management of EA, and help to timely identify environmental risk factors for EA in clinical practice.

Comparison of intranasal dexmedetomidine versus oral midazolam for premedication in pediatric patients: an updated meta-analysis with trial-sequential analysis

BACKGROUND

Midazolam is routinely used as preanesthetic medication in pediatric patients. Recently, dexmedetomidine has emerged as an alternative as a premedicant. We aimed to add more evidence about the efficacy and safety of two common routes of administration for pediatric premedication: oral midazolam versus intranasal dexmedetomidine.

METHODS

We systematically searched Randomized Controlled Trials (RCTs) involving patients ≤ 18 years old undergoing preanesthetic medication and comparing intranasal dexmedetomidine with oral midazolam. Risk Ratio (RR) and Mean Difference (MD) with 95% Confidence Intervals (95% CI) were computed using a random effects model. Trial-sequential analyses were performed to assess inconsistency.

RESULTS

Sixteen RCTs (1,239 patients) were included. Mean age was 5.5 years old, and most procedures were elective. There was no difference in satisfactory induction or mask acceptance (RR = 1.15, 95% CI 0.97-1.37; p = 0.11). There was a higher incidence of satisfactory separation from parents in the dexmedetomidine group (RR = 1.40; 95% CI 1.13-1.74; p = 0.002). Dexmedetomidine was also associated with a reduction in the incidence of emergence agitation (RR = 0.35; 95% CI 0.14-0.88; p = 0.02). Heart rate and mean arterial pressure were marginally lower in the dexmedetomidine group but without clinical repercussions.

CONCLUSION

Compared with oral midazolam, intranasal dexmedetomidine demonstrated better separation from parents and lower incidence of emergence agitation in pediatric premedication, without a difference in satisfactory induction. Intranasal dexmedetomidine may be a safe and effective alternative to oral midazolam for premedication in pediatric patients.

The effect of magnesium sulfate on emergence agitation in surgical adult patients undergoing general anesthesia: A systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVE

Investigating the effect of magnesium sulfate (MS) on emergence agitation (EA) in adult surgical patients following general anesthesia (GA).

DESIGN

Systematic literature review and meta-analysis (PROSPERO number: CRD42023461988).

SETTING

Review of published literature.

PATIENTS

Adults undergoing GA.

INTERVENTIONS

Intravenous administration of MS.

MEASUREMENTS

We searched PubMed/MEDLINE, EMBASE, the Cochrane Library, Scopus, and Web of Science for publications until September 14, 2023. The primary outcome was the incidence of EA, while the secondary outcomes included the impact of MS on postoperative agitation score (PAS), emergence variables and adverse events. Relative risk (RR) with 95% confidence interval (CI) measured dichotomous outcome, while standardized mean difference (SMD) or mean difference (MD) with 95% CI measured continuous outcomes.

MAIN RESULTS

Meta-analysis of five randomized controlled trials (RCTs) indicated that MS was associated with a lower incidence of EA at various time points (0 min: RR = 0.62, 95% CI [0.41, 0.95]; p = 0.183, I2 = 43.6%; 5 min: RR = 0.29, 95% CI [0.16, 0.52]; p = 0.211, I2 = 36%; 10 min: RR = 0.14, 95% CI [0.06, 0.32]; p = 0.449, I2 = 0%; 15 min: RR = 0.11, 95% CI [0.02, 0.55]; p = 0.265, I2 = 19.5%; 30 min: RR = 0.05, 95% CI [0.00, 0.91]; the postoperative period: RR = 0.21, 95% CI [0.09, 0.49]; p = 0.724, I2 = 0%;). Additionally, MS was associated with a reduced PAS at various time points except for 0 min. However, no significant differences were observed in extubation time, the length of stay in the post-anesthesia care unit, postoperative nausea and vomiting or total complications.

CONCLUSIONS

Limited available evidence suggests that MS was associated with a lower incidence of EA. Nevertheless, further high-quality studies are warranted to strengthen and validate the effect of MS in preventing EA in adult surgical patients.

Evaluation of Postoperative Discomfort After Strabismus Surgery Under General Anesthesia in Children: A Prospective Observational Study

Purpose

Strabismus surgery is most commonly performed on children under general anesthesia. However, few studies have focused on the postoperative discomfort in children after strabismus surgery. This study aimed to evaluate postoperative discomfort and the associated risk factors in children who underwent strabismus surgery under general anesthesia.

Patients and Methods

A single-center prospective observational study including 300 children who underwent strabismus surgery after general anesthesia was conducted. Patients' characteristics, preoperative anxiety, surgical and anesthesia data, discomfort within 24 hours after postanesthesia care unit were recorded. The primary outcome was the incidence of postoperative discomfort.

Results

Approximately 51.33% of the children complained of at least one of the following types of postoperative discomfort: postoperative nausea and vomiting (PONV) (23.00%), headache (4.33%), dizziness (20.33%) and emergence agitation (EA) (5.33%). Multivariate analysis indicated that history of motion sickness (P<0.001, odds ratio [OR]=3.72), and surgery in the dominant eye (P=0.010, OR=2.00) were independent predictors of postoperative discomfort; age was an independent predictor of EA (P<0.001, OR=0.36); prism diopter≥40 was an independent predictor of headache (P=0.005, OR=5.53); age (P=0.020, OR=1.12) and history of motion sickness (P=0.001, OR=2.80) were independent predictors of dizziness; history of motion sickness (P=0.001, OR=2.63) and surgery of inferior oblique anterior transposition (IOAT) (P=0.004, OR=3.10) were independent predictors of PONV.

Conclusion

The most frequent postoperative symptoms in children after undergoing strabismus surgery under general anesthesia are PONV, dizziness, EA, and headache. Younger age, larger angle of strabismus, history of motion sickness, surgery on the dominant eye, and surgery of IOAT may be additional risk factors for postoperative discomfort.

Operating Room Noise Environment and Behavior in Children Undergoing General Anesthesia: A Randomized Controlled Trial

Background

Excessive operating room noise impairs communication, distracts from monitoring equipment, and may increase patient and provider stress.

Aim

This study investigates the effects of reduced noise on perioperative behavior in children undergoing general anesthesia and on anesthesia provider response time.

Methods

Healthy children (the American Society of Anesthesiologists class I-II), 2-8 years of age, and their anesthesia providers were randomized into a control or treatment group exposed to reduced stimulation during induction and emergence. Primary outcomes were patient behavior and provider response time. Secondary outcomes were postoperative pain scores, provider responses exceeding 30 seconds, and median and maximum noise exposure.

Results

64 children (27 females and 37 males) were randomized into a control or treatment group, of whom 32 (50%) underwent tonsillectomy/adenoidectomy and 32 (50%) underwent dental procedures. The average age was 4.6 (SD 1.43) years. Children exposed to reduced noise were less likely to be "fussy about eating" (p=0.042), more "interested in what goes on around them" (p=0.008), and had fewer temper tantrums (p=0.004) on postoperative day one or two and on postoperative day five, six, or seven. No other differences were found between groups in behavioral assessment scores or provider response times.

Conclusions

Our study is the first to show that a low-stimulus environment improves postdischarge behavior. Provider response time was unaffected by reduced noise, and the average and peak noise exposure levels did not exceed national safety guidelines. This trial is registered with NCT03507855 and NCT03504553.

Effects of ultrasound-guided thoracolumbar interfascial plane block combined with general anaesthesia versus general anaesthesia alone on emergence agitation in children with cerebral palsy undergoing selective posterior rhizotomy: protocol for a randomised controlled clinical trial

INTRODUCTION

Selective posterior rhizotomy (SPR) is a preferred procedure for relieving spastic children with cerebral palsy, but it is associated with severe pain and significant emergence agitation (EA). The thoracolumbar interfascial plane (TLIP) block provides an effective blockade to the dorsal branch of the spinal nerve. We hypothesise that the TLIP block may be an effective tool to alleviate EA and postoperative pain scores in children with cerebral palsy undergoing SPR.

METHODS AND ANALYSIS

This study is a single-centre, randomised, parallel-controlled trial being conducted in Beijing, China. A total of 50 paediatric patients with cerebral palsy scheduled for SPR are randomised in a 1:1 ratio to receive bilateral TLIP block with 0.2% ropivacaine 0.5 mL/kg or control. Patients in the TLIP group receive general anaesthesia combined with TLIP block, while patients in the control group receive only general anaesthesia, without a TLIP block. The primary outcome is the Paediatric Anaesthesia Emergence Delirium Score. The secondary outcomes are the incidence of EA, the Wong-Baker Faces Pain-rating Scale, the perioperative haemodynamics, the intraoperative remifentanil and propofol dosage, the extubation time and recovery time, and adverse reactions.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Dongzhimen Hospital, Beijing University of Chinese Medicine on 21 September 2023 (2023DZMEC-379-02). Written informed consent is obtained from the legal guardian of each patient. The results of this study will be published in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ChiCTR2300076397.

Global Trends in Research Related to Emergence Agitation From 1978 to 2023: A Bibliometric Analysis

PURPOSE

Emergence agitation (EA) is a postoperative behavioral disorder characterized by a lack of connection between consciousness and behavior. Despite its clinical importance and prevalence in the postoperative setting, the research focus and knowledge structure remain to be systematically mapped. Therefore, we conducted a bibliometric analysis from 1978 to 2023 to address this gap. This study aims to excavate research hotspots, map knowledge structure, uncover emerging trends, and provide invaluable insights for guiding future research endeavors.

DESIGN

A bibliometric analysis of emergency agitation.

METHODS

We conducted a literature search in the Web of Science Core Collection for articles on EA published between 1978 and 2023. We collected data on countries, institutions, journals, authors, citations, and keywords. Subsequently, we comprehensively analyzed the gathered knowledge units using three tools, including VOSviewer, HistCite Pro, and ArcGIS Pro.

FINDINGS

From 1978 to 2023, we retrieved 948 pieces of literature on EA, with the number of publications increasing yearly. China ranked first in the number of publications (n = 253, 26.69%). The United States was the most cited and influential country, closely collaborating with other countries (5,661 citations, H-index 57, citations per publication 37.99, total link strength [TLS] 24). Yonsei University was the most productive and influential institution (n = 18, 1.9%, 427 citations, H-index 12, citations per publication 23.72). Shanghai Jiao Tong University had close collaborative relationships with other universities (TLS 7). The journal with the most publications and influence was Pediatric Anaesthesia (n = 46, 4.92%, H-index 32). Anaesthesia and Analgesia was the most cited journal (2,849 citations). M.T. Aouad was the most influential and productive author devoted to studying EA (n = 6, 0.63%, 173 citations, TLS 3,002). The most influential reference was "Greater incidence of delirium during recovery from sevoflurane anaesthesia in preschool boys" (author J. Aono, No. 19, IF = 8.8, Q1, local citation score 147). Hot research directions in EA include EA and emergence delirium, propofol and EA, risk factors of EA, EA in pediatric anaesthesia, dexmedetomidine, and EA induced by sevoflurane. Esketamine, nalbuphine, sugammadex, and dezocine are drugs that have received increased attention in recent years.

CONCLUSIONS

The study mapped the knowledge structure of EA and identified six prominent research directions, four drugs of significant research interest, and emerging thematic trends. These findings offer insights into the current state of research on EA, providing a comprehensive view of the field's landscape.

Magnitude of emergence agitation, its interventions and associated factors among paediatric surgical patients

BACKGROUND

Emergence agitation is a transient confusional state of a child associated with consciousness from general anaesthesia, commonly occurs in the postoperative setting which delays their recovery and exposes them to traumas. The main objective of the current study was to investigate the magnitude of emergence agitation, its interventions and associated factors among paediatric surgical patients at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

METHODS

Hospital based cross-sectional study with prospective follow-up framework was conducted on a paediatric surgical patients aged 2-14 years who underwent surgery under general anaesthesia between June 1 - October 30 2022. Stratified sampling method followed by simple random sampling technique was employed to reach study participants. Magnitude of emergence agitation and its interventions done at post-anaesthetic care units were recorded. Data analysis was carried out using a descriptive statistics method and the results were summarized using tables and diagrams. Bivariate analysis was done to identify causal relationship and multivariable analysis to assess the confounding effects of factors associated with emergence agitation. A p-value of less than 0.05 was considered statistically significant factor.

RESULTS

A total of 150 participants were included in the current study, where 107 (71.3%) were male and 97 (64.7%) were preschool aged. About 81 (54%) of care givers were female and majority of them have completed primary school. The mean (standard deviation) age of the participants was 6.4 (3.57) years. Around 42.7% of them developed emergence agitation with an average duration of 8.39 ± 4.45 minutes. Factors such as propofol administration at the end of procedure (OR of 0.104 with 95% CI [0.035, 0305]), Ear, nose, throat surgery and oral maxillofacial surgery (OR of 2.341 with 95% CI [1.051, 5.211]) and arrival of patient to recovery awake (OR of 0.456 95% CI [0.209, 0.994]) showed statistically significant association with emergence agitation.

CONCLUSION

Almost half of the study participants experienced emergence agitation which is high magnitude. Ear, nose, throat surgery and oral maxillofacial surgeries were predictive factors of emergence agitation while propofol administration at the end of procedure and arrival of patient to recovery awake significantly decreased risk of emergence agitation. Therefore, anaesthesia personnel should have essential skills and knowledge to effectively care for children perioperatively including to minimize and treat emergence agitation.

Effect of Short-term Deep Breathing Exercises on Perioperative Anxiety and Pain in Pediatric Orthopedic Patients: A Randomized Controlled Trial

PURPOSE

There are currently no pediatric studies examining the effects of deep breathing on perioperative pain and anxiety. This study sought to determine the effect of short-term deep breathing exercises on perioperative anxiety and pain in pediatric patients and their parents.

DESIGN

A randomized controlled trial was conducted in the Department of Orthopaedic Surgery where pediatric patients about to undergo surgery were allocated to a control group or a deep breathing group. In the intervention group, patients and their main guardian were guided to practice 10 minutes of deep breathing exercises twice a day for 3 to 4 days prior to surgery. Perioperative anxiety and pain were measured for both the children and parents as outcome indicators.

METHODS

Perioperative anxiety was measured using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) and state anxiety was measured using the State-Trait Anxiety Inventory (STAI). Patients reported their pain levels daily using the Wong-Baker FACES Pain Rating Scale. The following cutoffs were determined as high levels of anxiety: STAI (adult) > 44, STAI (child) > 36, and mYPAS-SF ≥ 30.

FINDINGS

No significant differences were found in the STAI, mYPAS-SF, and Wong-Baker FACES Pain Rating Scale scores of the patients between the intervention and control group. Overall statistics showed that parents had significantly higher postoperative state anxiety levels toward female children (44.93 ± 9.01) compared to male children (40.18 ± 9.89). Preoperative and postoperative parental state anxiety levels were correlated with the child's postoperative anxiety. Furthermore, children's postoperative state anxiety was slightly correlated with postoperative pain.

CONCLUSIONS

Short-term use of our deep breathing exercises was ineffective in reducing incidences of perioperative pain and anxiety in pediatric orthopedic patients. A longer period of deep breathing administration may be required for the intervention to be effective. Parental anxiety may have an effect on anxiety levels in children, and postoperative parental anxiety may be affected by the gender of the child.

Perioperative complications of middle cerebral artery occlusion in rats alleviated by human umbilical cord mesenchymal stem cells

For acute ischemic stroke treatment, the limitations of treatment methods and the high incidence of perioperative complications seriously affect the survival rate and postoperative recovery of patients. Human umbilical cord mesenchymal stem cells (hucMSCs) have multi-directional differentiation potential and immune regulation function, which is a potential cell therapy. The present investigation involved developing a model of cerebral ischemia-reperfusion injury by thrombectomy after middle cerebral artery occlusion (MCAO) for 90 min in rats and utilizing comprehensive multi-system evaluation methods, including the detection of brain tissue ischemia, postoperative survival rate, neurological score, anesthesia recovery monitoring, pain evaluation, stress response, and postoperative pulmonary complications, to elucidate the curative effect of tail vein injection of hucMSCs on MCAO's perioperative complications. Based on our research, it has been determined that hucMSCs treatment can reduce the volume of brain tissue ischemia, promote the recovery of neurological function, and improve the postoperative survival rate of MCAO in rats. At the same time, hucMSCs treatment can prolong the time of anesthesia recovery, relieve the occurrence of delirium during anesthesia recovery, and also have a good control effect on postoperative weight loss, facial pain expression, and lung injury. It can also reduce postoperative stress response by regulating blood glucose and serum levels of stress-related proteins including TNF-α, IL-6, CRP, NE, cortisol, β-endorphin, and IL-10, and ultimately promote the recovery of MCAO's perioperative complications.

Nalbuphine in Pediatric Emergence Agitation Following Cochlear Implantation: A Randomized Trial

Background

To investigate the effects of nalbuphine on emergency agitation (EA), which affects up to 80% of the children following otolaryngology procedures, in children undergoing cochlear implantation.

Methods

A prospective double-blinded randomized controlled clinical trial was conducted between November 2020 and October 2022. Eligible children, aged 6 months to 3 years old, were randomly assigned to either 0.1 mg/kg, 0.15 mg/kg, 0.2 mg/kg nalbuphine or 0.9% saline groups. EA was defined by the Pediatric Anesthesia Emergence Delirium (PAED) score ≥10. Extubation time, post-anesthesia care unit (PACU) length of stay, severe EA (PAED ≥ 15), peak PAED score, the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale, Ramsay sedation score, and adverse events were also recorded.

Results

A total of 104 children were enrolled, with 26 children in each group. Nalbuphine significantly reduced the EA occurrence from 73.1% in the saline group to 38.5%, 30.8%, and 26.9% in the 0.1 mg/kg, 0.15 mg/kg, and 0.2 mg/kg nalbuphine groups, respectively (P < 0.001), without affecting the extubation time and PACU length of stay. More children (34.6%) in the 0.9% saline group experienced severe EA. Higher dose nalbuphine (0.15 mg/kg, 0.2 mg/kg) showed lower peak PAED score, better analgesia and sedation effect compared with 0.1 mg/kg nalbuphine and saline groups. However, 0.2mg/kg nalbuphine caused undesired over-sedation in two (7.7%) children. No other adverse events were reported.

Conclusion

Young children undergoing cochlear implantation surgery were at a high risk of EA and postoperative pain, while 0.2 mg/kg nalbuphine might be an ideal candidate for EA and pain prevention when used under close monitoring.

Trial Registration

ChiCTR2000040407.

Global prevalence and risk factors of emergence delirium in pediatric patients undergoing general anesthesia: A systemic review and meta-analysis

PROBLEM

Emergence delirium (ED) in children post-general anesthesia has been persistently underestimated, impacting the well-being of children, nurses, and even parents. This study employs integrated analysis to establish a comprehensive understanding of ED, including its occurrence and related risk factors, emphasizing the imperative for enhanced awareness and comprehension among pediatric nursing care providers.

ELIGIBILITY CRITERIA

A systematic review and meta-analysis were conducted using four electronic databases, namely PubMed, CINAHL via EBSCOhost, Embase via Elsevier, and ProQuest Dissertations and Theses.

RESULTS

This meta-analysis included 16 studies involving 9598 children who underwent general anesthesia. The pooled prevalence of ED was 19.2% (95% confidence interval [CI] = 0.12 to 0.29), with younger patients exhibiting a higher prevalence of ED. ED research is scant in Africa and is mostly limited to the Asia Pacific region and Northern Europe. Neck and head surgery (odds ratio [OR] = 2.34, 95% CI = 1.29 to 4.27) were significantly associated with ED risk.

CONCLUSIONS

ED should be monitored in children who receive general anesthesia. In this study, ED had a prevalence rate of 19.2%, and head and neck surgery were significantly associated with ED risk. Therefore, healthcare professionals should carefully manage and prevent ED in children undergoing general anesthesia.

IMPLICATIONS

A comprehensive understanding of ED's prevalence and risk factors is crucial for enhancing nursing care. Adopting a family-centered care approach can empower parents with information to collaboratively care for their children, promoting a holistic approach to pediatric healthcare.

Safety of propofol-assisted deep extubation in the dental treatment of children-a retrospective, observational study

PURPOSE

Awake extubation and deep extubation are commonly used anesthesia techniques. In this study, the safety of propofol-assisted deep extubation in the dental treatment of children was assessed.

MATERIALS AND METHODS

Children with severe caries who received dental treatment under general anesthesia and deep extubation between January 2017 and June 2023 were included in this study. Data were collected on the following variables: details and time of anesthesia, perioperative vital signs, and incidence of postoperative complications. The incidence of laryngeal spasm (LS) was considered to be the primary observation indicator.

RESULTS

The perioperative data obtained from 195 children undergoing dental treatment was reviewed. The median age was 4.2 years (range: 2.3 to 9.6 years), and the average duration of anesthesia was 2.56 h (range 1 to 4.5 h). During intubation with a videoscope, purulent mucus was found in the pharyngeal cavity of seven children (3.6%); LS occurred in five of them (2.6%), and one child developed a fever (T = 37.8 °C) after discharge. Five children (2.6%) experienced emergence agitation (EA) in the recovery room. Also, 13 children (6.7%) experienced epistaxis; 10 had a mild experience and three had a moderate experience. No cases of airway obstruction (AO) and hypoxemia were recorded. The time to open eyes (TOE) was 16.3 ± 7.2 min. The incidence rate of complications was 23/195 (11.8%). Emergency tracheal reintubation was not required. Patients with mild upper respiratory tract infections showed a significantly higher incidence of complications (P < 0.001).

CONCLUSIONS

Propofol-assisted deep extubation is a suitable technique that can be used for pediatric patients who exhibited non-cooperation in the outpatient setting. Epistaxis represents the most frequently encountered complication. Preoperative upper respiratory tract infection significantly increases the risk of complications. The occurrence of EA was notably lower than reported in other studies.

Safety and Efficacy of Intranasal Ketamine for Minor Pediatric Procedures: A Systemic Literature Review

Compared to intravenous anesthetics, intranasal medication for sedation is a less invasive approach. Intranasal ketamine (IK) is a widely used medication for procedural sedation. Hence, a systematic review was conducted with the aim of evaluating the safety and efficacy of IK among pediatric patients used for procedural sedation. For this purpose, a literature search was conducted on PubMed, Web of Science, and MEDLINE. A total of 247 search results appeared after running the developed query and eight articles passed through the inclusion and exclusion criteria and were included in the study. Most of the studies used 4 to 7 mg/kg dose of IK for pediatric patients. It was found that there was a moderate correlation between the age and dose of IK. Similarly, the dose of IK also had a direct and moderate correlation with the onset of sedation. Regarding the reported side effects, most of the studies reported nausea and vomiting as side effects of IK. Hence, it could be concluded from the study findings that effective sedation can be achieved by using 4 to 7 mg/kg dose of IK. The reported side effects of IK were minor while parental satisfaction with the drug was very high. Therefore, it can be concluded that the use of IK for procedural sedation among pediatric patients is safe and effective.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Oral Dexmedetomidine Achieves Superior Effects in Mitigating Emergence Agitation and Demonstrates Comparable Sedative Effects to Oral Midazolam for Pediatric Premedication: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Background: Oral midazolam is the most commonly used sedative premedication agent in pediatric patients. While effective, oral midazolam cannot reduce the incidence of emergence agitation. Oral dexmedetomidine may be effective in providing satisfactory sedation and reduce the incidence of emergence agitation, although the results of different randomized controlled trials are conflicting. Methods: This study enrolled randomized controlled trials (RCTs) examining premedication with oral dexmedetomidine versus oral midazolam in pediatric patients undergoing general anesthesia. PubMed, the Cochrane Library, Embase, and the Web of Science database were searched from their inception until June 2023. The outcomes were the incidence of satisfactory preoperative sedation, satisfactory sedation during separation from parents, satisfactory sedation during anesthesia induction using an anesthesia mask, and the incidence of emergence agitation. Results: A total of 9 RCTs comprising 885 patients were analyzed. Our data revealed comparable effects of dexmedetomidine and midazolam with respect to satisfactory preoperative sedation and a satisfactory incidence of sedation during parental separation and mask acceptance before anesthesia induction. Notably, our data revealed that the rate of emergence agitation was significantly lower in pediatric patients receiving dexmedetomidine (n = 162) than in those receiving midazolam (n = 159) (odds ratio = 0.16; 95% confidence interval: 0.06 to 0.44; p < 0.001; I2 = 35%). Conclusions: Data from this meta-analysis revealed comparable effects for premedication with oral dexmedetomidine or oral midazolam with respect to satisfactory sedation; furthermore, premedication with oral dexmedetomidine more effectively mitigated emergence agitation in pediatric patients receiving general anesthesia compared with oral midazolam.

Effect of transcutaneous electrical acupoint stimulation on postoperative pain in pediatric orthopedic surgery with the enhanced recovery after surgery protocol: a prospective, randomized controlled trial

STUDY OBJECTIVE

To evaluate the safety and effectiveness of transcutaneous electrical acupoint stimulation (TEAS) in postoperative analgesia following pediatric orthopedic surgery with the enhanced recovery after surgery (ERAS) protocol.

DESIGN

Prospective randomized controlled trial.

SETTING

The Seventh Medical Center of the Chinese People's Liberation Army General Hospital.

PARTICIPANTS

Eligible participants were children aged 3-15 years who were scheduled to undergo orthopedic surgery of the lower extremities under general anesthesia.

INTERVENTIONS

A total of 58 children were randomly allocated into two groups: TEAS (n = 29) and sham-TEAS (n = 29). The ERAS protocol was used in both groups. In the TEAS group, the bilateral Hegu (LI4) and Neiguan (PC6) acupoints were stimulated starting from 10 min before anesthetic induction until the completion of surgery. In the sham-TEAS group, the electric stimulator was also connected to the participants; however, electrical stimulation was not applied.

MEASURES

The primary outcome was the severity of pain before leaving the post-anesthesia care unit (PACU) and at postoperative 2 h, 24 h, and 48 h. Pain intensity was measured with the Faces Pain Scale-Revised (FPS-R).

RESULTS

None of the participants had any TEAS-related adverse reactions. In comparison with the sham-TEAS group, FPS-R scores in the TEAS group were significantly decreased before leaving the PACU and at postoperative 2 h and 24 h (p < 0.05). The incidence of emergence agitation, intraoperative consumption of remifentanil, and time to extubation were significantly reduced in the TEAS group. Furthermore, the time to first press of the patient-controlled intravenous analgesia (PCIA) pump was significantly longer, the pressing times of the PCIA pump in 48 h after surgery was significantly decreased, and parental satisfaction was significantly improved (all p < 0.05).

CONCLUSION

TEAS may safely and effectively relieve postoperative pain and reduce the consumption of perioperative analgesia in children following orthopedic surgery with the ERAS protocol.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2200059577), registered on May 4, 2022.

Application of the concept of fast-track surgery in pediatric ophthalmic surgery

PURPOSE

To explore the effects of the fast-track surgery (FTS) approach during the perioperative period of ophthalmic surgery in pediatric patients.

METHODS

A bidirectional cohort design was applied in this study. The traditional nursing mode was followed in relation to 40 pediatric patients admitted for ophthalmic surgery in March 2018 (control group), whereas the FTS mode was followed with regard to 40 pediatric patients admitted for ophthalmic surgery in April 2018 (observation group). The effects of the FTS mode were determined by comparing the postoperative pain score, restlessness score, and the incidence of postoperative nausea and vomiting between the two groups.

RESULTS

The pain and restlessness scores of the patients at 4hours after surgery in the observation group were significantly decreased compared with those in the control group (P<0.01). The incidence of postoperative nausea and vomiting in the observation group was also slightly lower than that in the control group (P>0.05).

CONCLUSION

A perioperative FTS-based nursing mode can effectively alleviate the postoperative pain and restlessness of pediatric patients without increasing their stress response.

Effects of Pharmacological Intervention on Recovery After Sevoflurane Anesthesia in Children: a Network Meta-analysis of Randomized Controlled Trials

Sevoflurane, commonly administered to children as anesthesia, often leads to emergence delirium (ED). Currently, a consensus is lacking among clinicians regarding pharmacological interventions to improve recovery. To determine an effective approach, we compared the effects of several drugs in lowering the incidence of ED after sevoflurane anesthesia in children.We searched online databases for relevant randomized controlled trials (59 studies selected; 5199 NMA-eligible participants) and performed a frequentist network meta-analysis (NMA). This study was registered on PROSPERO (number CRD: 42022329939).All included studies had a low to moderate risk of overall bias. The incidence of ED after sevoflurane anesthesia in children differed according to other drugs administered, and were ranked from high to low according to the surface under the cumulative ranking curve (SUCRA).Sufentanil (91.2%) and dexmedetomidine (77.6%) were more likely to reduce the incidence (SUCRA value) of ED, whereas the placebo (6.5%), ramelteon (11.1%), and magnesium (18%) were less likely to reduce the incidence of ED. Remifentanil (89.3%) ranked first in shortening emergence time, followed by placebo (82.4%) and ketamine (69.7%). Placebo shortened extubation time, followed by remifentanil (66.5%) and alfentanil (61.4%).Sufentanil and remifentanil lowered sevoflurane-induced ED incidences among children and shortened the emergence time more effectively than other drugs. Most adjuvant drugs that are combined with sevoflurane either do not change or may even prolong extubation time. Further research and clinical trials are required to support and update these conclusions.

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

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.

The effect of intranasal dexmedetomidine administration on emergence agitation or delirium in pediatric patients after general anesthesia: A meta-analysis of randomized controlled trials

BACKGROUND

Emergence agitation or delirium can occur in pediatric patients after anesthesia. Dexmedetomidine is known to reduce the impairment of postoperative cognitive function.

AIMS

This study aimed to identify the role of intranasal administration of dexmedetomidine in lowering the development of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

METHODS

Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. The primary outcome was the proportion of patients who underwent emergence agitation or emergence delirium after the surgery. Secondary outcomes included emergence time and incidence of postoperative nausea and/or vomiting. We estimated the odds ratio and mean difference with 95% confidence intervals for the determination of effect size using a random-effects model.

RESULTS

In total, 2103 pediatric patients from 20 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 13.6% in the dexmedetomidine group and 33.2% in the control group. The pooled effect size revealed that intranasal dexmedetomidine administration significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery under general anesthesia (odds ratio 0.25, 95% confidence interval 0.18-0.34; p = .0000; I²  = 37.74%). Additionally, significant difference was observed in emergence time between the two groups (mean difference 2.42, 95% confidence interval 0.37-4.46; p = .021; I²  = 98.40%). Children in the dexmedetomidine group had a significantly lower incidence of postoperative nausea and/or vomiting than those in the control group (odds ratio 0.39, 95% confidence interval 0.24-0.64; p = .0002; I²  = 0.00%).

CONCLUSIONS

Intranasal dexmedetomidine reduced the incidence of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

Nalbuphine reduces the incidence of emergence agitation in children undergoing Adenotonsillectomy: A prospective, randomized, double-blind, multicenter study

OBJECTIVE

To evaluate the effect of nalbuphine on emergence agitation (EA) in children undergoing adenotonsillectomy.

DESIGN

Multicenter, prospective, double-blind, randomized controlled trial.

SETTING

The First People's Hospital of Foshan and three other participating institutions in China, from April 2020 to December 2021.

PATIENTS

Eight hundred patients, 3-9 years of age, American Society of Anesthesiologists (ASA) classification I or II, undergoing elective adenotonsillectomy were included.

INTERVENTIONS

Nalbuphine (0.1 mg/kg) or saline was administered intravenously.

MEASUREMENTS

The incidence of EA; the pediatric anesthesia emergence delirium (PAED) scale; and the faces, legs, activity, cry, and consolability (FLACC) scales. Extubation time, duration of post-anesthesia care unit (PACU) stay, anesthesia nurses' and parents' satisfaction, and other side effects.

MAIN RESULTS

The incidence of EA in the nalbuphine group was lower than that in the saline group 30 min after extubation (10.28% vs. 28.39%, P = 0.000). In addition, the FLACC scores in the nalbuphine group were lower than those in the saline group 30 min after extubation (P < 0.05). Furthermore, the proportion of moderate-to-severe pain cases (FLACC scores >3) was significantly lower in the nalbuphine group than in the saline group (33.58% vs. 60.05%, P = 0.000). Adjusting the imbalance of postoperative pain intensity, the risk of EA was still lower in the nalbuphine group at 0 min (OR, 0.39; 95% CI, 0.26-0.60; P = 0.000), (OR, odds ratio; CI, confidence interval), 10 min (OR, 0.39; 95% CI, 0.19-0.79; P = 0.01), and 20 min (OR, 0.27; 95% CI, 0.08-0.99; P = 0.046) than in the saline group. There were no significant differences in extubation time, duration of PACU stay, nausea and vomiting, or respiratory depression between the two groups (P > 0.05).

CONCLUSION

Nalbuphine reduced the incidence of EA in children after adenotonsillectomy under general anesthesia, which may be involved in both analgesic and non-analgesic pathways.

Effect of S-ketamine administered at the end of anesthesia on emergence delirium in preschool children undergoing tonsillectomy and/or adenoidectomy

Background: S-ketamine (the S-isomer of ketamine) is twice as potent as the racemic mixture of this agent and carries fewer side effects when administered to humans. Information regarding the use of S-ketamine for the prevention of emergence delirium (ED) is limited. Thus, we evaluated the effect of S-ketamine administered at the end of anesthesia on ED in preschool children undergoing tonsillectomy and/or adenoidectomy. Methods: We investigated 108 children aged 3-7 years, who were scheduled for elective tonsillectomy and/or adenoidectomy under general anesthesia. They were randomly assigned to receive either S-ketamine 0.2 mg/kg or an equal volume of normal saline at the end of anesthesia. The primary outcome was the highest score on the pediatric anesthesia ED (PAED) scale during the first 30 min post-surgery. The secondary outcomes included the incidence of ED (defined as a score of ≥ 3 on Aono scale), pain score, time to extubation, and incidences of adverse events. Multivariate analyses were also performed using logistic regression to evaluate the independent factors predictive of ED. Results: The median (interquartile range) PAED score of the S-ketamine group (0 [0, 3]) was significantly lower than that in the control group (1 [0, 7]) (estimate median difference = 0, 95% confidence interval -2 to 0, p = 0.040). Significantly fewer patients in the S-ketamine group had an Aono scale score ≥ 3 (4 [7%] vs. 12 [22%], p = 0.030). Patients in the S-ketamine group also had a lower median pain score than did control subjects (4 [4, 6] vs. 6 [5, 8], p = 0.002). The time to extubation and incidences of adverse events were comparable between the two groups. However, multivariate analyses indicated that except S-ketamine use, pain scores, age and duration of anesthesia were independent factors predictive of ED. Conclusion: S-ketamine (0.2 mg/kg) administered at the end of anesthesia effectively reduced the incidence and severity of ED in preschool children undergoing tonsillectomy and/or adenoidectomy without prolonging the time to extubation or increasing adverse events. However, S-ketamine use was not an independent factor predictive of ED.

Application of Continuous Sacral Block Guided by Ultrasound After Comprehensive Sacral Canal Scanning in Children Undergoing Laparoscopic Surgery: A Prospective, Randomized, Double-Blind Study

Purpose

The present study aimed to explore the effects of continuous sacral block on the postoperative pain of children and the satisfaction of the nurses in post-anesthesia care unit (PACU). Also, the influence of the modified protocol of continuous sacral block was investigated.

Patients and Methods

A total of 60 children undergoing laparoscopic surgery were randomly divided into two groups: GI and GC groups. The general anesthesia was induced with midazolam, propofol, sufentanil and succinylcholine in both groups. In addition, the patients were subjected to continuous sacral block with levobupivacaine in group GC. The modified protocol of continuous sacral block was divided into three steps: comprehensive lumbar and sacral vertebral canal scanning by ultrasound, catheterization and administration. The EVENDOL pain scales and pediatric anesthesia emergence delirium scales of the children were evaluated at 5 min after extubation (T₃), 90 min (T₄), and 4 h (T₅) after the operation. The nurses' satisfaction scores at T₃ -T₄ and adverse events, such as nausea and vomiting, were also recorded, after the operation.

Results

After ultrasonic scanning, one patient in group GC was excluded due to the sacral hiatus atresia, which might lead to failure of catheterization. Data of 59 patients were collected for statistical analysis. Compared to the GI group, the EVENDOL scores and the pediatric anesthesia emergence delirium scales were reduced at T₃, T₄, and T₅ (P < 0.05) in group GC. Furthermore, there was a higher rank of PACU nurses' satisfaction in the GC group compared to the GI group (P < 0.05).

Conclusion

Based on the modified protocol, continuous sacral block provides reliable and safety analgesia for children undergoing laparoscopic surgery, thereby improving the satisfaction of PACU nurses.

Intramuscular Ketamine Effect on Postnasal Surgery Agitation: A Prospective Double-Blinded Randomized Controlled Trial

This study investigates the effect of intramuscular ketamine on emergence agitation (EA) following septoplasty and open septorhinoplasty (OSRP) when administered at subanesthetic doses at the end of surgery. A random sample of 160 ASA I-II adult patients who underwent septoplasty or OSRP between May and October, 2022, was divided into two groups of eighty patients each: ketamine (Group K) and saline (Group S) with the latter serving as the control group. At the end of surgery immediately after turning off the inhalational agent, Group K was administered with intramuscular 2 ml of normal saline containing 0.7 mg/kg ketamine and Group S with 2 ml of intramuscular normal saline. Sedation and agitation scores at emergence from anesthesia were recorded after extubation using the Richmond Agitation-Sedation Scale (RASS). The incidence of EA was higher in the saline group than in the ketamine group (56.3% vs. 5%; odds ratio (OR): 0.033; 95% confidence interval (CI): 0.010-0.103; p < 0.001). Variables associated with a higher incidence of agitation were ASA II classification (OR: 3.286; 95% (CI): 1.359-7.944; p=0.008), longer duration of surgery (OR: 1.010; 95% CI: 1.001-1.020; p=0.031), and OSRP surgery (OR: 2.157; CI: 1.056-5.999; p=0.037). The study concluded that the administration of intramuscular ketamine at a dose of 0.7 mg/kg at the end of surgery effectively reduced the incidence of EA in septoplasty and OSRP surgery.

Efficacy and safety of intranasal midazolam versus intranasal ketamine as sedative premedication in pediatric patients: a meta-analysis of randomized controlled trials

BACKGROUND

Intranasal midazolam and ketamine have been widely used as sedative premedication in children. It is difficult to determine which one yields better sedative effects for clinical practice. We conducted the present meta-analysis by summarizing the evidences to evaluate the efficacy and safety of intranasal midazolam versus intranasal ketamine as sedative premedication in pediatric patients.

METHODS

We searched PubMed, Embase, and Cochrane Library from inception to April 2022. All randomized controlled trials (RCTs) used intranasal midazolam and ketamine as sedatives in children were enrolled. The risk of bias in RCTs was assessed by Cochrane risk of bias tool. Condition of parental separation, anesthesia induction or facemask acceptance, sedation level, different hemodynamic parameters and adverse events were considered as the outcomes in our study.

RESULTS

A total of 16 studies with 1066 patients were enrolled. Compared with midazolam, administration of intranasal ketamine might be associated with severer changes in hemodynamics parameters including mean blood pressure (SMD = -0.53, with 95% CI [-0.93, -0.13]) and heart rate (HR) (SMD = -1.39, with 95% CI [-2.84, 0.06]). Meanwhile, administration of intranasal midazolam was associated with more satisfactory sedation level (61.76% vs 40.74%, RR = 1.53, with 95%CI [1.28, 1.83]), more rapid onset of sedation (SMD = -0.59, with 95%CI [-0.90, -0.28]) and more rapid recovery (SMD = -1.06, with 95%CI [-1.83, -0.28]). Current evidences also indicated that the differences of various adverse effects between two groups were not significant.

CONCLUSIONS

Given that administration of midazolam via intranasal route provides more satisfactory sedative level with less fluctuation of hemodynamics parameters and more rapid onset and recovery, it might be considered as the preferred sedative premedication for pediatric patients compared to ketamine. However, the widespread evidences with low or moderate quality indicated that superiority of intranasal midazolam in pediatric sedation needs to be confirmed by more studies with high quality and large sample size in future.

TRIAL REGISTRATION

The protocol of present study was registered with PROSPERO (CRD42022321348).

Effectiveness of Intravenous Ibuprofen on Emergence Agitation in Children Undergoing Tonsillectomy with Propofol and Remifentanil Anesthesia: A Randomized Controlled Trial

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).

The Effects of Remifentanil and Fentanyl on Emergence Agitation in Pediatric Strabismus Surgery

Emergence agitation (EA) is one of the main concerns in the field of pediatric anesthesia using sevoflurane. We investigated the effects of remifentanil and fentanyl on the incidence of EA in pediatric patients undergoing strabismus surgery. Ninety children were randomly allocated into two groups and received either remifentanil (group R: intraoperatively remifentanil 0.2 μg/kg/min) or fentanyl (group F: fentanyl 2 μg/kg at anesthetic induction) intraoperatively. After surgery, EA incidence was assessed using a four-point agitation scale and Pediatric Anesthesia Emergence Delirium (PAED) scale in the post-anesthesia care unit. Face, leg, activity, cry, and consolability (FLACC) scores for postoperative pain were also assessed. The incidence of EA using the four-point agitation scale (scores ≥ 3) was similar in both groups (remifentanil group, 28.89% vs. fentanyl group, 24.44%). Similar results were obtained using the PAED scale (scores > 12), with an incidence of 33.33% in the remifentanil group and 26.67% in the fentanyl group. Differences in FLACC scores were not found to be statistically significant. A single bolus administration of fentanyl during anesthetic induction and continuous infusion of remifentanil during surgery had similar effects on the EA incidence in these pediatric patients.

Intraoperative use of low-dose dexmedetomidine for the prevention of emergence agitation following general anaesthesia in elderly patients: a randomized controlled trial

OBJECTIVE

To clarify the effect of an intraoperative low-dose dexmedetomidine infusion on emergence agitation following general anaesthesia in elderly patients.

METHODS

Eighty elderly patients (> 64-years-old) following elective general anaesthesia for radical cancer surgeries were randomly allocated into two groups (n = 40 each): the dexmedetomidine group (Group D) and the normal saline group (Group C). Anaesthesia was maintained with continuous intravenous infusion of dexmedetomidine at - 0.2 µg kg^-1 h^-1 in Group D, and an equal volume of normal saline (0.5 ml kg^-1 h^-1) was given in Group C. All patients were observed for 30 min in the post-anaesthesia care unit (PACU), AFPS and NRS were recorded every 2 min, and the total doses of nalbuphine and fentanyl were calculated in the PACU. MAP and HR were recorded at the time of 10 min (T1), 20 min (T2), 30 min (T3) after dexmedetomidine or saline pumping, and before extubation (T4), immediately after extubation (T5), and 5 min after extubation (T6). We also documented some durations, including anaesthesia duration (D1), surgery duration (D2), duration from the end of surgery to extubation (D3), and emergence agitation duration (D4).

RESULTS

The MAP in Group C was significantly higher than that in Group D (P < 0.05), and there were no significant changes between the two groups in HR and MAP within each time point and D1, D2, D3, and D4. The incidence of agitation, NRS score and total dose of nalbuphine and fentanyl were all lower in Group D than in Group C (P < 0.05).

CONCLUSION

An intraoperative low-dose dexmedetomidine continuous infusion can reduce emergence agitation following general anaesthesia in elderly patients (> 64-years-old), remain stable in terms of haemodynamics, and not lead to delays in anaesthesia recovery time and extubation time.

Comparison of the Effect of Ketamine, Ketamine-Midazolam and Ketamine-Propofol on Post-Tonsillectomy Agitation in Children

Background

Emergence agitation (EA) in children is one of the most common complications following anaesthesia. We aimed to compare the effect of ketamine, ketamine-midazolam and ketamine-propofol on EA after tonsillectomy.

Methods

This study was a randomised, double-blind clinical trial conducted on 162 children undergoing adenotonsillectomy surgery. The participants were randomly divided into three groups of receiving ketamine (0.5 mg/kg) (N = 54), ketamine (0.5 mg/kg) + propofol (1 mg/kg) (N = 54) and ketamine (0.5 mg/kg) + midazolam (0.01 mg/kg) (N = 54) 10 min before the end of the operation. At the time of the patients’ entry into the post-anaesthesia care unit (PACU) and at intervals of 5 min, 10 min and 20 min after that, consciousness, mobility, breathing, circulation and SpO₂ were recorded. Modified Aldrete recovery score (MARS), the objective pain score (OPS) and Richmond agitation-sedation scale (RASS) were also evaluated.

Results

At the time of entrance to the PACU and 5 min later, the ketamine-midazolam and ketamine-propofol groups had lower RASS scores than the ketamine group (P < 0.001); after 10 min and 20 min, the ketamine-propofol group showed the lowest RASS score (P < 0.001). Ketamine-propofol group had a significantly lower MARS score at all-time points (P < 0.001). Recovery time was the longest for the ketamine-propofol group (P = 0.008).

Conclusion

The ketamine-midazolam group had lower RASS, greater haemodynamic stability and MARS values without delayed awakening.

Predictive Value of Preoperative Profiling of Serum Metabolites for Emergence Agitation After General Anesthesia in Adult Patients

Background: Emergence agitation (EA) in adult patients under general anesthesia leads to increased postoperative complications and heavy medical burden. Unfortunately, its pathogenesis has not been clarified until now. The purpose of the present study was to explore the relationship between preoperative serum metabolites and EA. Methods: We used an untargeted metabolic analysis method to investigate the different metabolomes in the serum of EA patients and non-EA patients undergoing elective surgical procedures after the induction of general anesthesia. A Richmond Agitation-Sedation Scale score ≥ +2 was diagnosed as EA during postoperative emergence. Non-EA patients were matched with EA patients according to general characteristics. Preoperative serum samples of the two groups were collected to investigate the association between serum metabolites and EA development. Results: The serum samples of 16 EA patients with 34 matched non-EA patients were obtained for metabolic analysis. After screening and alignment with databases, 31 altered metabolites were detected between the two groups. These metabolites were mainly involved in the metabolism of lipids, purines, and amino acids. Analyses of receiver-operating characteristic curves showed that the preoperative alterations of choline, cytidine, glycerophosphocholine, L-phenylalanine, oleamide, and inosine may be associated with adult EA. Conclusion: Multiple metabolic abnormalities (including those for lipids, purines, and amino acids) and other pathological processes (e.g., neurotransmitter imbalance and oxidative stress) may contribute to EA. Several altered metabolites in serum before surgery may have predictive value for EA diagnosis. This study might afford new metabolic clues for the understanding of EA pathogenesis.

Effects on Recovery of Pediatric Patients Undergoing Total Intravenous Anesthesia with Propofol versus Ketofol for Short-Lasting Laparoscopic Procedures

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.

Application and effects of an early childhood education machine on analgesia and sedation in children after cardiothoracic surgery

OBJECTIVE

To study the effect of an early childhood education machine on sedation and analgesia in children after cardiothoracic surgery.

METHODS

A prospective randomized controlled study was conducted in a provincial hospital in China. Fifty-two patients (aged from 1 to 5 years) underwent cardiothoracic surgery (including: ventricular septal defect, patent ductus arteriosus, atrial septal defect, pulmonary stenosis, pulmonary sequestration and congenital cystic adenomatoid lung malformation) were divided into the study group (n = 26) and the control group (n = 26). The patients in the study group underwent intervention with an early childhood education machine (uniform type) in addition to routine standard treatment and nursing, while the patients in the control group only received routine standard treatment and nursing. Richmond agitation sedation score (RASS) and face, legs, activity, cry, consolability (FLACC) score of all of the patients were evaluated, and the negative emotions (self-rating anxiety scale (SAS) score and self-rating depression scale (SDS) score) of the parents of the two groups were compared.

RESULTS

There was no significant difference in the general clinical data between the two groups. The RASS and FLACC scores in the study group were significantly lower than those in the control group, and the SAS and SDS scores of the parents in the study group were significantly lower than those in the control group.

CONCLUSION

The application of an early childhood education machine for children after cardiothoracic surgery can effectively reduce postoperative agitation, improve sedation and analgesia of the patients, and ease the pessimistic mood of the patients' parents.

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

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

Emergence agitation after the cleft lip or palate surgery in pediatric patients: a prospective study

OBJECTIVE

The pediatric patients after the cleft lip or palate surgery have high incidences of postoperative complications. Emergence agitation is a common complication. It is also a mild complication compared with lingual swelling and other airway-related complications, which are more often expected in children. However, it can cover signs of hypoxic episodes that appear immediately after surgery, because enough monitoring of an agitated child is not possible. The study aimed to discuss the occurrence of EA after cleft lip or palate surgery in pediatric patients, and further to provide a basis for later interventions.

METHODS

This prospective study included 214 patients aged 3 months to 6 years old at a tertiary stomatological teaching hospital. We calculated the EA scores for every patient when they entered PACU, were in PACU, and left from PACU, and the score ranges from 1 to 5 point. The patients occurred agitation if they scored from 3 to 5 on the 5-point scale, and the patients needed medication and care if they had a score of 4 or 5.

RESULT

The results showed that the EA scores of 69.63% (n = 149) among patients were 3 or higher when they entered PACU, 40.65% (n = 87) were 3 or higher when they were in PACU, and 21.03% (n = 45) were 3 or higher when they left from PACU. Whether they are children with cleft lip, cleft palate, or horizontal cleft, the EA scores had a significant difference among different timings when entering PACU, in PACU, and leaving PACU (P = 0.000). Further comparison showed that the EA score of patients was the highest when entering PACU, and the lowest when leaving PACU. A significant difference in the EA scores was found among the patients with cleft lip, cleft palate, and horizontal cleft when they were in PACU (P = 0.024), further comparison showed that the EA score of the patients with cleft lip was lower than patients with cleft palate or horizontal cleft. While there were no statistical differences in the EA scores among the patients with cleft lip, cleft palate, and horizontal cleft when they entered PACU and left from PACU (P > 0.05).

CONCLUSION

Children had a high incidence of EA after cleft lip or cleft palate or horizontal cleft surgery, especially when they entered PACU. Children after cleft palate and horizontal cleft surgery had higher incidences of EA than cleft lip surgery when they were in PACU.

Comparative efficacy of ancillary drugs in sevoflurane-related emergence agitation after paediatric adenotonsillectomy: A Bayesian network meta-analysis

WHAT IS KNOWN AND OBJECTIVE

The comparative efficacy of ancillary drugs on sevoflurane-related emergence agitation (EA) in paediatric anaesthesia for adenotonsillectomy remains unclear. The purpose of this Bayesian network meta-analysis was to investigate the efficacy of ancillary drugs on sevoflurane-related EA in paediatric anaesthesia for adenotonsillectomy.

METHODS

MEDLINE, Embase, the Cochrane Library and Web of Science databases were electronically searched to identify randomized controlled trials (RCTs) of different ancillary drugs used in adenotonsillectomy from inception to April 2019. Two reviewers independently screened the literature, extracted data and assessed the risk of bias in included studies. Subsequently, a network meta-analysis was performed using the R software and RevMan 5.3 software.

RESULTS AND DISCUSSION

We included 25 RCTs, involving 2151 participants. The proportion of patients with sevoflurane-related EA was significantly lower in the dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil and clonidine groups than in the placebo group (P < .05). Fentanyl was superior to sufentanil (P < .05), whereas dexmedetomidine was superior to fentanyl (P < .05). Among ancillary drugs, dexmedetomidine (90.04%) showed the highest possibility of reducing the risk of EA, followed by fentanyl (87.45%), remifentanil (63.85%), ketamine (52.07%), midazolam (51.27%), clonidine (49.94%), propofol (29.89%), sufentanil (21.38%) and placebo (4.09%).

WHAT IS NEW AND CONCLUSION

Evidence suggests that the effects of dexmedetomidine in reducing the risk of sevoflurane-related EA in paediatric anaesthesia for adenotonsillectomy were better than the effects of other drugs. However, large, high-quality RCTs are required to further confirm this.

Emergence agitation: current knowledge and unresolved questions

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.

Effects of intravenous and mask induction on post-operative emergence delirium in pediatric patients undergoing tonsillectomy with or without adenoidectomy

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.

Video game distraction and anesthesia mask practice reduces children's preoperative anxiety: A randomized clinical trial

PURPOSE

The study aims to evaluate the effectiveness of combined video game distraction and anesthesia mask exposure and shaping intervention as compared to conventional preoperative preparation on the preoperative anxiety, anesthesia induction compliance and emergence delirium of children undergoing day-case surgery.

DESIGN AND METHODS

The CONSORT guidelines were followed in the current study; a randomized clinical trial, two groups, pre posttest, between subjects design with 1:1 allocation ratio was employed. Children (5-11 years of age; N = 128) admitted for day case surgery were invited to participate in the study. Sixty-four children were assigned to the intervention group receiving combined videogame distraction and anesthesia mask exposure and shaping intervention, and 64 children were assigned to the control group.

RESULTS

The results showed that children in the intervention group reported statistically significant lower anxiety scores than the children in the control group at three preoperative points of time: postintervention t = 4.48, p < .001, at the time of transfer to the operation room t = 10.18; p < .001 and during anesthesia induction t = 7.76; p < .001. In addition, compared with the children in the control group, fewer children in the intervention group demonstrated poor anesthesia induction compliance χ²  = 3.91; p = .04. The results, however, did not reveal statistically significant differences in children's emergence delirium scores.

PRACTICE IMPLICATION

Combined video game distraction and anesthesia mask exposure and shaping are simple, safe, and time-effective intervention that the nurses can implement at the day of surgery to mitigate children anxiety and to enhance their anesthesia induction compliance.

Comparison of single minimum dose administration of dexmedetomidine and midazolam for prevention of emergence delirium in children: a randomized controlled trial

PURPOSE

Emergence delirium (ED) is common in children after sevoflurane anesthesia and should be prevented for patient safety. A prospective, double-blind, randomized, controlled study was performed to compare the efficacy of minimal dosage of midazolam versus dexmedetomidine to prevent ED in children undergoing tonsillectomy.

METHODS

Seventy children aged 24 months to 12 years were allocated to receive midazolam (0.03 mg/kg) or dexmedetomidine (0.3 µg/kg) 5 min before the end of surgery. The incidence and severity of ED were assessed using a four-point scale and the pediatric anesthesia emergence delirium scale, respectively. The emergence time and postoperative pain scores were also evaluated.

RESULTS

The incidence of ED was 31.3% in the midazolam group and 26.5% in the dexmedetomidine group (P = 0.668). The severity of ED was similar in both groups (9.6 ± 5.8 in the midazolam group, vs. 8.1 ± 5.9 in the dexmedetomidine group, P = 0.299). The emergence time was comparable in the two groups [11.0 (8.3-13.8) min in midazolam group vs. 12.0 (10.0-13.5) min in dexmedetomidine group (P = 0.218)]. Postoperative pain score was higher in the midazolam group [0 (0-1)] than in the dexmedetomidine group [0 (0-0)] (P = 0.011).

CONCLUSION

Dexmedetomidine and midazolam at single minimum dosages had equal effectiveness to prevent ED in children without delaying emergence time, when administered at the end of surgery. With regards to postoperative analgesic efficacy, although dexmedetomidine showed statistically significant higher analgesic effect than midazolam, further clinical investigations are needed to validate our findings.

Effects of peri-operative intravenous administration of dexmedetomidine on emergence agitation after general anesthesia in adults: a meta-analysis of randomized controlled trials

Objective

The aim of the current meta-analysis was to assess the effect of dexmedetomidine on emergence agitation (EA) and the recovery outcomes after general anesthesia in adults.

Methods

We searched the PubMed, the Cochrane Central Register of Controlled Trials, Embase, Web of Science and clinicaltrials.gov for relevant randomized controlled trials (RCTs) investigating the effects of dexmedetomidine on the EA in adults after general anesthesia compared with placebo. The primary outcome was the incidence of EA. Secondary outcomes included other recovery outcomes after general anesthesia.

Results

Twelve RCTs (842 participants) met the eligibility criteria. A conventional random-effects meta-analysis demonstrated that peri-operative intravenous dexmedetomidine could be effective for the prevention of EA [risk ratio (RR) 0.49, Trial Sequential Analysis (TSA)-adjusted 95% confidence interval (CI) 0.35–0.68, P<0.00001]. In addition, the TSA indicated that the meta-analysis for the incidence of EA reached the required information size (370). Lower number of patients receiving dexmedetomidine required analgesia (P=0.0009). Extubation time was longer (P=0.03) and hypotension (P=0.03) was more common with dexmedetomidine. Moreover, no difference was found in the other outcomes.

Conclusion

Dexmedetomidine was shown to effectively decrease the incidence of EA and to reduce postoperative analgesic requirements. Yet, other recovery outcomes including extubation time, length of PACU stay, postoperative residual sedation, hypotension, bradycardia as well as postoperative nausea and vomiting provided no data that could be used to form final conclusions.

Effect of ancillary drugs on sevoflurane related emergence agitation in children undergoing ophthalmic surgery: a Bayesian network meta-analysis

BACKGROUND

The comparative efficacy of ancillary drugs on sevoflurane related emergence agitation (EA) in children undergoing ophthalmic surgery remains controversial.

METHODS

The databases were retrieved in an orderly manner from the dates of their establishment to October, 2018, including PubMed, The Cochrane Library and Web of Science, to collect randomized controlled trials (RCT) of different anesthetic drugs combined with sevoflurane for ophthalmic surgery. Then a network meta-analysis was conducted using R and Stata 12.0 softwares.

RESULTS

The meta-analysis showed that, in reducing sevoflurane related EA, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil and clonidine were superior to placebo (P < 0.05). The network meta-analysis showed that the effects of ancillary drugs combine with sevoflurane in reducing risk of EA in children undergoing ophthalmic surgery was superior to placebo: dexmedetomidine (OR = 0.17, 95% CrI 0.12-0.22), ketamine (OR = 0.30, 95% CrI 0.11-0.49), propofol (OR = 0.24, 95% CrI 0.09-0.63), fentanyl (OR = 0.16, 95% CrI 0.08-0.56), midazolam (OR = 0.20, 95% CrI 0.09-0.40), sufentanil (OR = 0.27, 95% CrI 0.14-0.41), remifentanil (OR = 0.18, 95% CrI 0.08-0.54) and clonidine (OR = 0.14, 95% CrI 0.07-0.41). The SUCRA of placebo, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil, clonidine were respectively 0.26, 77.93, 27.71, 42.8, 69.43, 52.89, 59.83, 57.62 and 61.53%.

CONCLUSIONS

The effects of dexmedetomidine combine with sevoflurane in reducing risk of emergence agitation in children undergoing ophthalmic surgery was superior to other drugs.

Effects of tramadol on emergence agitation after general anesthesia for nasal surgery: A retrospective cohort study

Emergence agitation (EA) is common after nasal surgery. Strong opioids and N-methyl-D-aspartate (NMDA) receptor antagonists prevent EA. Tramadol also acts as an opioid receptor agonist and an NMDA receptor antagonist, but few studies have evaluated the effects of tramadol on EA. This retrospective study investigated whether tramadol is effective for reducing EA in adult patients undergoing nasal surgery.Of 210 adult patients undergoing a nasal surgical procedure under general anesthesia, the medical records of 113 were analyzed retrospectively. The patients were divided into 2 groups: patients who received tramadol during the operation (tramadol group, n = 52) and patients who did not (control group, n = 61). The incidence of EA, recovery time, changes in hemodynamic parameters, postoperative pain scores, and adverse events were compared between the 2 groups.The incidence of EA was higher in the control group than in the tramadol group (50.8% [31/61] vs 26.9% [14/52]; odds ratio 2.805; 95% confidence interval, 1.3 to 6.2; P = .010). Changes in systolic blood pressure in the 2 groups were similar, whereas changes in heart rate during emergence differed depending on the group (P = .020), although pairwise comparisons did not reveal any differences between the groups. Recovery time, postoperative pain scores, and adverse events were similar in the 2 groups.In adult patients undergoing nasal surgery, tramadol infusion decreases the incidence of EA after sevoflurane anesthesia without delaying recovery or increasing the number of adverse events.

Comparison of effects of propofol and ketofol (Ketamine-Propofol mixture) on emergence agitation in children undergoing tonsillectomy

BACKGROUND

The aim of this study was to compare the effect of propofol and ketofol (ketamine-propofol mixture) on EA in children undergoing tonsillectomy.

METHOD

In this randomized clinical trial, 87 ASA class I and II patients, aged 3-12 years, who underwent tonsillectomy, were divided into two groups to receive either propofol 100 µg/kg/min (group p, n=44) or ketofol : ketamine 25 µg/kg/min + propofol 75 µg/kg/min (group k, n= 43). Incidence and severity of EA was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scales on arrival at the recovery room, and 10 and 30 min after that time.

RESULTS

There was no statistically significant difference in demographic data between the two groups. In the ketofol group, the need for agitation treatment and also mean recovery duration were lower than in the propofol group (30 and 41%, and 29.9 and 32.7 min), without statistically significant difference (P value=0.143 and P value=0.187). Laryngospasm or bronchospasm occurred in 2 patients in each group and bleeding was observed in only one individual in the ketofol group.

CONCLUSION

Infusion of ketofol in children undergoing tonsillectomy provides shorter recovery time and lower incidence of EA despite the non significant difference with propofol.

Effect of ultrasound-guided lumbar plexus block on emergence agitation in children undergoing hip surgery: study protocol for a randomized controlled trial

Background

Emergence agitation (EA) is a common postoperative issue in children that causes self-injury, increases stress on healthcare team members, and even leads to postoperative maladaptive behavioral changes in children. Clear answers regarding a ‘gold standard’ for prevention of EA are not available. Pain is regarded as an important causative factor of EA, and ultrasound-guided lumbar plexus block is a safe and efficient anesthetic method that can provide satisfactory pain relief in pediatric hip surgery. The purpose of our study is to determine whether ultrasound-guided lumbar plexus block can reduce the incidence of EA in children undergoing hip surgery.

Methods/design

We designed a prospective, randomized, controlled, blinded trial to determine the effect of ultrasound-guided lumbar plexus block on EA. A total of 100 American Society of Anesthesiologists class I–II children (1–6 years old) scheduled for elective hip surgery will be recruited for this study. Participants will be randomized at a 1:1 ratio to receive either ultrasound-guided lumbar plexus block or fentanyl after the induction of general anesthesia. The primary outcome is the incidence of EA 30 min after emergence from anesthesia using the Pediatric Anesthesia Emergence Delirium (PAED) score. The secondary outcomes are the severity and duration of EA 30 min after emergence from anesthesia using the PAED score, postoperative pain evaluated by the Children’s Hospital of Eastern Ontario Pain Scale, and the incidence of postoperative adverse events. Randomization will be conducted using a computer-generated randomization schedule. Outcome assessors and data collectors will be blinded to the group allocations. Assessments will be performed before surgery, intraoperatively, and postoperatively at every time point.

Discussion

Our hypothesis in this trial is that ultrasound-guided lumbar plexus block can decrease the incidence of EA in children undergoing elective hip surgery. This trial will provide clinical answers to verify our hypothesis. If our hypothesis is confirmed, the results could provide a safe method to prevent EA.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-INR-17011525. Registered on 30 May 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3140-3) contains supplementary material, which is available to authorized users.