Emergence delirium in children: a Brazilian survey

Postoperative agitation or delirium in paediatric patients. What we know and how to avoid it

Emergence delirium or postoperative agitation is the name given to the state of altered consciousness that occurs after surgery and especially affects pediatric patients. Its incidence is not negligible, reaching 80% of cases in certain studies. It is frequently confused with other clinical entities, for which reason a scale has been validated to facilitate its diagnosis. Risk factors include age under 5 years, the presence of pain after surgery and especially intense preoperative anxiety. Pediatric emergence delirium presents as an adverse event after surgery and influences patient safety by significantly increasing patient comorbidity. It is essential to recognize the entity, as well as its risk factors, in order to apply effective preventive measures to reduce its incidence and intensity when it occurs.

Effect of Intranasal Dexmedetomidine or Midazolam for Premedication on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomy and Adenoidectomy: A Randomized Clinical Trial

IMPORTANCE

Perioperative respiratory adverse events (PRAEs) are the most common complication during pediatric anesthesia, and they may be affected by the administration of preoperative sedatives.

OBJECTIVE

To investigate the effect of intranasal dexmedetomidine or midazolam used for premedication on the occurrence of PRAEs.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, double-blind, randomized clinical trial was conducted among children aged 0 to 12 years undergoing elective tonsillectomy and adenoidectomy from October 2020 to June 2021 at Children's Hospital of Xuzhou Medical University, Xuzhou, China. Data analysis was performed from June to October 2021.

INTERVENTIONS

Children were randomly assigned to 3 groups: the midazolam group received intranasal midazolam (0.1 mg/kg), and the dexmedetomidine group received intranasal dexmedetomidine (2.0 μg/kg) for premedication. The normal saline group received intranasal 0.9% saline for control.

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference in the incidence of PRAEs among the 3 groups. The secondary outcomes were the frequency of the individual PRAEs, including the incidence of such events during the induction and recovery periods, postoperative emergence delirium, postoperative pain score, sedation success rate, and heart rate values.

RESULTS

A total of 384 children (median [IQR] age, 7 [5-10] years; 227 boys [59.1%]) were enrolled and randomized; 373 data sets were available for intention-to-treat analysis (124 children in the midazolam group, 124 children in the dexmedetomidine group, and 125 children in the normal saline group). After the data were adjusted for age, sex, American Society of Anesthesiologists physical status, body mass index, obstructive sleep apnea, upper respiratory tract infection, and passive smoking, children in the midazolam group were more likely to experience PRAEs than those in the normal saline group (70 of 124 children [56.5%] vs 51 of 125 children [40.8%]; adjusted odds ratio [aOR], 1.99; 95% CI, 1.18-3.35), whereas the dexmedetomidine group had a significantly lower PRAEs incidence than the normal saline group (30 of 124 children [24.2%] vs 51 of 125 children [40.8%]; aOR, 0.45; 95% CI, 0.26-0.78). Compared with the dexmedetomidine group, the midazolam group had a higher risk of PRAEs (aOR, 4.44; 95% CI, 2.54-7.76), but no other serious clinical adverse events were observed.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, intranasal midazolam used for premedication was associated with increased incidence of PRAEs, whereas premedication with intranasal dexmedetomidine was associated with reduced incidence of PRAEs. Where clinically appropriate, anesthesiologists should consider using intranasal dexmedetomidine for sedation in children undergoing tonsillectomy and adenoidectomy.

TRIAL REGISTRATION

Chinese Clinical Trial Register Identifier: ChiCTR2000038359.