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

Can Dexmedetomidine Influence Recovery Profiles from General Anesthesia in Nasal Surgery?

Objectives Dexmedetomidine has sympatholytic, sedative, anesthetic, and analgesic effects, as well as vasoconstrictive effects, which may help prevent hypotension under general anesthesia. This meta-analysis aimed to perform a systematic review of the literature and investigate the effect of dexmedetomidine on perioperative morbidity following nasal surgery and its adverse effects. Data Sources MEDLINE, SCOPUS, and the Cochrane database. Review Methods Two authors independently searched the databases from their inception to March 2017. Studies were selected that compared perioperative dexmedetomidine administration (dexmedetomidine groups) with a placebo or remifentanil (control groups) with regard to intraoperative morbidity, including surgical time, bleeding amount, hypotension, and bradycardia during operation, and postoperative morbidity, such as emergence agitation, nausea and vomiting, and sedation after operation. Results Surgical time, intraoperative blood loss, dose of inhaled anesthetic gas, dose of fentanyl, postoperative pain, and incidence of emergence agitation were significantly lower in the dexmedetomidine group versus the placebo group. In contrast, there were no significant differences in intraoperative hemodynamic stability and postoperative residual sedation and nausea and vomiting between groups. Additionally, compared with remifentanil (a currently widely used agent), dexmedetomidine was superior in view of postoperative pain and intraoperative blood pressure control. Conclusion This meta-analysis shows that the systemic administration of dexmedetomidine can decrease surgical time, intraoperative blood loss, and doses of intraoperative inhaled anesthetic gas and fentanyl as compared with placebo. It can also decrease postoperative pain and incidence of the emergence agitation. Due to the small number of studies, further clinical trials are needed to confirm these results.

Effects of Fentanyl on Emergence Agitation in Children under Sevoflurane Anesthesia: Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

The goal of this meta-analysis study was to assess the effects of fentanyl on emergence agitation (EA) under sevoflurane anesthesia in children.

SUBJECTS AND METHODS

We searched electronic databases (PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials) for articles published until December 2014. Randomized controlled trials (RCTs) that assessed the effects of fentanyl and placebo on EA under sevoflurane anesthesia in children that the outcome were the incidence of EA, postoperative pain, emergence time or adverse effects were included in this meta-analysis.

RESULTS

A total of 16 studies, including 1362 patients (737 patients for the fentanyl group and 625 for the placebo group), were evaluated in final analysis. We found that administration of fentanyl decreased the incidences of EA (RR = 0.37, 95% CI 0.27~0.49, P<0.00001) and postoperative pain (RR = 0.59, 95% CI 0.41~0.85, P = 0.004) but increased the incidence of postoperative nausea and vomiting (PONV) (RR = 2.23, 95% CI 1.33~3.77, P = 0.003). The extubation time (WMD = 0.71 min, 95% CI 0.12~1.3, P = 0.02), emergence time (WMD = 4.90 min, 95% CI 2.49~7.30, P<0.0001), and time in the postanesthesia care unit (PACU) (WMD = 2.65 min, 95% CI 0.76~4.53, P = 0.006) were slightly increased. There were no significant differences in the time to discharge of day patients (WMD = 3.72 min, 95% CI -2.80~10.24, P = 0.26).

CONCLUSION

Our meta-analysis suggests that fentanyl decreases the incidence of EA under sevoflurane anesthesia in children and postoperative pain, but has a higher incidence of PONV. Considering the inherent limitations of the included studies, more RCTs with extensive follow-up should be performed to validate our findings in the future.

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children

BACKGROUND

Sevoflurane is an inhaled volatile anaesthetic that is widely used in paediatric anaesthetic practice. Since its introduction, postoperative behavioural disturbance known as emergence agitation (EA) or emergence delirium (ED) has been recognized as a problem that may occur during recovery from sevoflurane anaesthesia. For the purpose of this systematic review, EA has been used to describe this clinical entity. A child with EA may be restless, may cause self-injury or may disrupt the dressing, surgical site or indwelling devices, leading to the potential for parents to be dissatisfied with their child's anaesthetic. To prevent such outcomes, the child may require pharmacological or physical restraint. Sevoflurane may be a major contributing factor in the development of EA. Therefore, an evidence-based understanding of the risk/benefit profile regarding sevoflurane compared with other general anaesthetic agents and adjuncts would facilitate its rational and optimal use.

OBJECTIVES

To compare sevoflurane with other general anaesthetic (GA) agents, with or without pharmacological or non-pharmacological adjuncts, with regard to risk of EA in children during emergence from anaesthesia. The primary outcome was risk of EA; secondary outcome was agitation score.

SEARCH METHODS

We searched the following databases from the date of inception to 19 January 2013: CENTRAL, Ovid MEDLINE, Ovid EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost), Evidence-Based Medicine Reviews (EBMR) and the Web of Science, as well as the reference lists of other relevant articles and online trial registers.

SELECTION CRITERIA

We included all randomized (or quasi-randomized) controlled trials investigating children < 18 years of age presenting for general anaesthesia with or without surgical intervention. We included any study in which a sevoflurane anaesthetic was compared with any other GA, and any study in which researchers investigated adjuncts (pharmacological or non-pharmacological) to sevoflurane anaesthesia compared with no adjunct or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the databases, decided on inclusion eligibility of publications, ascertained study quality and extracted data. They then resolved differences between their results by discussion. Data were entered into RevMan 5.2 for analyses and presentation. Comparisons of the risk of EA were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Sevoflurane is treated as the control anaesthesia in this review. Sensitivity analyses were performed as appropriate, to exclude studies with a high risk of bias and to investigate heterogeneity.

MAIN RESULTS

We included 158 studies involving 14,045 children. Interventions to prevent EA fell into two broad groups. First, alternative GA compared with sevoflurane anaesthesia (69 studies), and second, use of an adjunct with sevoflurane anaesthesia versus sevoflurane without an adjunct (100 studies). The overall risk of bias in included studies was low. The overall Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) assessment of the quality of the evidence was moderate to high. A wide range of EA scales were used, as were different levels of cutoff, to determine the presence or absence of EA. Some studies involved children receiving potentially inadequate or no analgesia intraoperatively during painful procedures.Halothane (RR 0.51, 95% CI 0.41 to 0.63, 3534 participants, high quality of evidence) and propofol anaesthesia were associated with a lower risk of EA than sevoflurane anaesthesia. Propofol was effective when used throughout anaesthesia (RR 0.35, 95% CI 0.25 to 0.51, 1098 participants, high quality of evidence) and when used only during the maintenance phase of anaesthesia after sevoflurane induction (RR 0.59, 95% CI 0.46 to 0.76, 738 participants, high quality of evidence). No clear evidence was found of an effect on risk of EA of desflurane (RR 1.46, 95% CI 0.92 to 2.31, 408 participants, moderate quality of evidence) or isoflurane (RR 0.76, 95% CI 0.46 to 1.23, 379 participants, moderate quality of evidence) versus sevoflurane.Compared with no adjunct, effective adjuncts for reducing the risk of EA during sevoflurane anaesthesia included dexmedetomidine (RR 0.37, 95% CI 0.29 to 0.47, 851 participants, high quality of evidence), clonidine (RR 0.45, 95% CI 0.31 to 0.66, 739 participants, high quality of evidence), opioids, in particular fentanyl (RR 0.37, 95% CI 0.27 to 0.50, 1247 participants, high quality of evidence) and a bolus of propofol (RR 0.58, 95% CI 0.38 to 0.89, 394 participants, moderate quality of evidence), ketamine (RR 0.30, 95% CI 0.13 to 0.69, 231 participants, moderate quality of evidence) or midazolam (RR 0.57, 95% CI 0.41 to 0.81, 116 participants, moderate quality of evidence) at the end of anaesthesia. Midazolam oral premedication (RR 0.81, 95% CI 0.59 to 1.12, 370 participants, moderate quality of evidence) and parental presence at emergence (RR 0.91, 95% CI 0.51 to 1.60, 180 participants, moderate quality of evidence) did not reduce the risk of EA.One or more factors designated as high risk of bias were noted in less than 10% of the included studies. Sensitivity analyses of these studies showed no clinically relevant changes in the risk of EA. Heterogeneity was significant with respect to these comparisons: halothane; clonidine; fentanyl; midazolam premedication; propofol 1 mg/kg bolus at end; and ketamine 0.25 mg/kg bolus at end of anaesthesia. With investigation of heterogeneity, the only clinically relevant changes to findings were seen in the context of potential pain, namely, the setting of adenoidectomy/adenotonsillectomy (propofol bolus; midazolam premedication) and the absence of a regional block (clonidine).

AUTHORS' CONCLUSIONS

Propofol, halothane, alpha-2 agonists (dexmedetomidine, clonidine), opioids (e.g. fentanyl) and ketamine reduce the risk of EA compared with sevoflurane anaesthesia, whereas no clear evidence shows an effect for desflurane, isoflurane, midazolam premedication and parental presence at emergence. Therefore anaesthetists can consider several effective strategies to reduce the risk of EA in their clinical practice. Future studies should ensure adequate analgesia in the control group, for which pain may be a contributing or confounding factor in the diagnosis of EA. Regardless of the EA scale used, it would be helpful for study authors to report the risk of EA, so that this might be included in future meta-analyses. Researchers should also consider combining effective interventions as a multi-modal approach to further reduce the risk of EA.

Dexmedetomidine reduces emergence agitation after tonsillectomy in children by sevoflurane anesthesia: a case-control study

OBJECTIVE

To evaluate the efficacy and safety of dexmedetomidine for emergence agitation after tonsillectomy in children.

METHODS

120 ASA physical status I and II children, aged 5-14 years, undergoing anesthesia for tonsillectomy, were randomly divided into 3 groups: Placebo group, the low dexmedetomidine concentration group and the high dexmedetomidine concentration group. Before the entrance of the operating room (OR), all of the children received intravenous injection 40 μg kg(-1) midazolam to reduce anxiety at first, and then dexmedetomidine was given intravenously at an initial loading dose of 0.5 μg kg(-1) or 1 μg/kg over a 10-min period via a computer controlled infusion pump followed by a maintenance infusion of 0.2 μg kg(-1)h(-1) or 0.4 μg kg(-1)h(-1)over the surgery. The heart rate, SpO(2) and mean arterial blood pressure were recorded for each patient in both operation room and PACU. The designated time points: at the start of the anesthetic induction, at the discontinuation of inhalational agents, at first opening of eyes, at time to remove endotracheal tube were recorded. After patient arrival at the PACU, VAS score, RSS, the occurrence of emergence agitation were recorded every 5 min for the first 30 min and every 10 min for the next 30 min after endotracheal tube was removed.

RESULTS

There was significant difference in the incidence of emergence agitation between Placebo group and the high concentration group when endotracheal tube was removed (P<0.05). There was significant difference in the VAS pain scores and in the RSS between three groups at the time of extubation, as well as 5 min and 10 min after extubation (P<0.05).

CONCLUSIONS

Dexmedetomidine appears to be safe and effective to reduce the incidence of early emergence agitation in children after tonsillectomy. Initial loading dose of 1.0 μg kg(-1) followed by a maintenance infusion of 0.4 μg kg(-1)h(-1) is better choice for children received tonsillectomy.

Effect of ketamine versus thiopental sodium anesthetic induction and a small dose of fentanyl on emergence agitation after sevoflurane anesthesia in children undergoing brief ophthalmic surgery

Background

Emergence agitation (EA) in children after sevoflurane anesthesia is common. The purpose of this study was to compare the incidences of EA between ketamine and thiopental sodium induction in children underwent sevoflurane anesthesia. We also evaluated if a small dose of fentanyl could reduce the incidence of EA.

Methods

The patients who were scheduled for strabismus or entropion surgery were divided into 4 groups. The patients in Groups 1 and 2 were induced anesthesia with ketamine 1.5 mg/kg; those in Groups 3 and 4 were induced with thiopental sodium 5 mg/kg. The patients in Groups 1 and 3 received an injection of fentanyl 1.5 µg/kg, whereas the patients in Groups 2 and 4 received IV saline of the same volume. Anesthesia was maintained with sevoflurane. The recovery characteristics and EA in recovery room were assessed.

Results

The incidence of EA was significantly higher in Groups 2 and 4 and there was no difference between Groups 2 and 4. Group 2 had almost an eleven-fold higher risk of developing EA than did Group 1, and the incidence of EA in Group 4 was sixty-nine-fold higher than that of Group 1. The risk factor for EA was only the kind of medication. Preoperative anxiety had no significant correlation with EA.

Conclusions

The incidence of EA after sevoflurane anesthesia is similar between ketamine and thiopental sodium anesthetic induction in children undergoing pediatric ophthalmic surgery. Also, the addition of a small dose of fentanyl after anesthetic induction decreases the incidence of EA.

The potential for mu-opioid receptor agonists to be anti-emetic in humans: a review of clinical data

In animal models of vomiting, mu-opioid (MOP, OP(3)) receptors mediate both emesis and anti-emesis. mu-receptors within the blood-brain barrier, mediating anti-emesis, are more rapidly accessible to lipid-soluble mu-opioid receptor agonists such as fentanyl than to morphine, and fentanyl has broad-spectrum anti-emetic effects in a number of species. Whether a similar situation exists in humans is not known. A search was performed for clinical studies comparing the emetic side effects of opioids administered peri-operatively in an attempt to identify differences between morphine and more lipid-soluble mu-receptor-selective agonists such as fentanyl. Overall, the evidence appears to suggest that fentanyl and other phenylpiperidines are associated with less nausea and vomiting than morphine, but not all studies support this, and fentanyl-like drugs are associated with nausea and vomiting per se. Good evidence, however, exists to show that fentanyl and alfentanil do not cause more nausea and vomiting than the ultra fast-acting remifentanil. Because remifentanil is cleared rapidly post-operatively, such trials suggest that the emetic side effects of fentanyl and alfentanil are minimal. The clinical evidence, although limited, is at least consistent with the possibility that central mu-opioid receptors may mediate anti-emesis in humans. It is possible that the role of mu-opioid agonists in anti-emesis may become clearer in the future as a result of the use of peripheral mu-opioid receptor antagonists.

Successful and safe delivery of anesthesia and perioperative care for children with complex special health care needs

STUDY OBJECTIVE

To determine the utilization of anesthesia resources by children with complex special health care needs.

DESIGN

Observational, inception cohort study of medical records.

SETTING

Urban, pediatric, tertiary-care hospital.

MEASUREMENTS

All general anesthetic cases were screened for preexisting complex special health care needs. Medical records were reviewed for demographic, clinical, and outcome data.

MAIN RESULTS

435 children with complex special health care needs accounted for 479 delivered general anesthetic cases. This figure represented 14% of the total 3,437 cases presenting during the study period. It also represented 22% (49 of 224) of all cancellations. Down syndrome was the most identifiable developmental disorder (n = 43, 9%). Another 143 (30%) cases showed preexisting technology dependence. Scheduled surgical procedures (n = 425, 89%) comprised the majority of cases. Intraoperative and recovery room complications occurred in 6 (1%) and 133 (28%) cases, respectively. Eleven (2.3%) cases required unplanned post-anesthetic hospital ward or pediatric intensive care unit admission. Documentation of health care proxy or resuscitation status was not identified in any child under 18 years, and in only 4 of 33 children older than 18 years.

CONCLUSIONS

Children with complex special health care needs represented one out of 7 of all pediatric general anesthetic cases at a tertiary-care, academic center.