1
|
Han SM, Kwon SY, In JH, Joo JD. Enhancing ketamine anesthesia with midazolam and fentanyl for children's ear surgery: a prospective randomized study. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2024; 41:207-212. [PMID: 38778719 PMCID: PMC11294792 DOI: 10.12701/jyms.2024.00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Myringotomy with tympanostomy tube insertion (MTI) is a superficial surgical procedure used to prevent hearing loss in children with serous otitis media. Intravenous anesthesia, often ketamine, is preferred for this procedure because of its ability to induce sedation without compromising airway reflexes. However, ketamine alone may be insufficient and potentially lead to spontaneous movement during surgery. This study evaluated the effectiveness of midazolam and fentanyl as adjuvants to ketamine in reducing spontaneous movement during MTI and enhancing the quality of recovery. METHODS This study involved two groups of 30 patients each: one group received intravenous ketamine (1.5 mg/kg) with an equal volume of normal saline (K group), while the other received a combination of midazolam, fentanyl, and ketamine (0.05 mg/kg, 1 μg/kg, and 1.5 mg/kg, respectively; MFK group). We assessed side effects, intraoperative patient movement, surgeon satisfaction, and emergence agitation scores. RESULTS The MFK group exhibited significantly lower scores for patient movement (p<0.01) and emergence agitation (p<0.01) and markedly higher surgeon satisfaction scores (p<0.01) than the K group. CONCLUSION Administering a midazolam-fentanyl-ketamine combination effectively reduced spontaneous movement during surgery and emergence agitation during recovery without prolonging discharge times in children undergoing MTI.
Collapse
Affiliation(s)
| | - So Young Kwon
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jang Hyeok In
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Deok Joo
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
2
|
Behavioral and Emotional Disorders in Children and Their Anesthetic Implications. CHILDREN-BASEL 2020; 7:children7120253. [PMID: 33255535 PMCID: PMC7759846 DOI: 10.3390/children7120253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 12/29/2022]
Abstract
While most children have anxiety and fears in the hospital environment, especially prior to having surgery, there are several common behavioral and emotional disorders in children that can pose a challenge in the perioperative setting. These include anxiety, depression, oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, post-traumatic stress disorder, and autism spectrum disorder. The aim of this review article is to provide a brief overview of each disorder, explore the impact on anesthesia and perioperative care, and highlight some management techniques that can be used to facilitate a smooth perioperative course.
Collapse
|
3
|
Riley B, Kawai K, Irace AL, Leung P, Adil E. Perioperative pain control and tympanostomy tube outcomes. Int J Pediatr Otorhinolaryngol 2020; 138:110337. [PMID: 33152955 DOI: 10.1016/j.ijporl.2020.110337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate perioperative pain management regimens as they relate to tympanostomy tube outcomes. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral children's hospital. SUBJECTS and Methods: The medical records of patients ≤18 years old who underwent tympanostomy tube placement were reviewed for indications, perioperative pain medications, post anesthesia recovery unit (PACU) measures, and tympanostomy tube occlusion rates. RESULTS Four hundred and fifty-five patients met inclusion criteria. Median age was 1.7 years (interquartile range: 1.2-3.3 years). Recurrent acute otitis media (n = 239, 52.5%) was the most common indication. All patients were American Society of Anesthesiologists (ASA) class 1 (n = 244, 58.1%) or 2 (n = 176, 41.9%). Fentanyl alone (n = 321, 70.6%) was the most common intraoperative analgesic administered followed by ketorolac alone (n = 40, 8.8%), and fentanyl and ketorolac together (n = 58, 12.8%). There was no significant difference in FLACC pain score at discharge and recovery time (minutes) also did not differ by intraoperative analgesia group (34.3 ± 15.2 for fentanyl; 36.2 ± 13.0 for ketorolac; 31.0 ± 12.5 for fentanyl and ketorolac together). Forty nine patients (11.6%) had an occluded tympanostomy tube at follow-up. Patients ≤1 year of age had a significantly higher risk of tube occlusion than patients >1 year of age (23.7% vs. 8.9%; p < 0.001). There was no significant difference in tube occlusion rates based on indication for tube placement, history of tube placement, intraoperative findings, or intraoperative pain regimen. CONCLUSIONS Ketorolac is a reasonable non-narcotic alternative to fentanyl which provides equal pain control and does not increase tube occlusion rates.
Collapse
Affiliation(s)
- Bobbie Riley
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| | - Alexandria L Irace
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | - Peggy Leung
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | - Eelam Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
4
|
The Addition of Intravenous Propofol and Ketorolac to a Sevoflurane Anesthetic Lessens Emergence Agitation in Children Having Bilateral Myringotomy with Tympanostomy Tube Insertion: A Prospective Observational Study. CHILDREN-BASEL 2020; 7:children7080096. [PMID: 32824173 PMCID: PMC7464540 DOI: 10.3390/children7080096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022]
Abstract
The aim of this prospective observational study was to determine if children undergoing bilateral myringotomy and tympanostomy tube insertion with a sevoflurane anesthetic plus intravenous propofol and ketorolac experienced a lower incidence of emergence agitation than those receiving a sevoflurane anesthetic alone. Duration of procedure, length of stay in post-anaesthesia care and level of nursing effort required to care for patients were also assessed. In this study, 49 children younger than 13 years of age received a sevoflurane anesthetic. Fifty-one percent of these patients also received a single injection of propofol 1 mg/kg and ketorolac 0.5 mg/kg at the end of the procedure. Patients were assessed for emergence agitation using the Pediatric Anesthesia Emergence Delirium scale in the post-anaesthesia care unit. Four children receiving a sevoflurane anesthetic alone experienced emergence agitation, while no children receiving propofol and ketorolac experienced emergence agitation (p = 0.05). The length of stay until discharge from the hospital was 6.98 min longer for patients receiving propofol and ketorolac but did not reach statistical significance (p = 0.23). Nurses reported greater ease in caring for patients receiving the propofol and ketorolac injection (recovery questionnaire score 4.50 vs. 3.75, p = 0.002). In this study, adding a single injection of intravenous propofol and ketorolac to the end of a brief sevoflurane anesthetic for bilateral myringotomy with tube insertion was associated with a lower incidence of emergence agitation without significantly increasing the time to discharge from the hospital.
Collapse
|
5
|
Suvvari P, Mishra S, Bhatnagar S, Garg R, Bharati SJ, Gupta N, Kumar V, Khan M. Comparison of Intranasal Dexmedetomidine Versus Intranasal Ketamine as Premedication for Level of Sedation in Children Undergoing Radiation Therapy: A Prospective, Randomised, Double-Blind Study. Turk J Anaesthesiol Reanim 2020; 48:215-222. [PMID: 32551449 PMCID: PMC7279870 DOI: 10.5152/tjar.2019.45087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/26/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Radiation therapy is indicated in many solid tumours in children. Absolute immobility is required to precisely position children for optimal delivery of radiation energy to the target tissues, improve success rate and reduce the damage to nearby normal tissues. Intranasal (IN) administration of drugs is well tolerated, effective and fast acting. The primary aim of the present study was to evaluate the effectiveness of IN ketamine and dexmedetomidine for providing sedation in children before shifting to the radiotherapy suite. The secondary objective was to assess the requirement of propofol dosage in these patients. METHODS A total of 243 children aged between 1 and 5 years scheduled to undergo external beam radiotherapy were randomised to receive 5 mg kg-1 ketamine (group K, n=80), 2.5 μg kg-1 dexmedetomidine (group D, n=85) or 0.5 ml of saline (group S, n=78) in each nostril. After 45 min, sedation score was measured according to the modified Ramsay score (MRS) at the time of shifting for radiation. Time to awakening and time to discharge after the procedure were also noted. RESULTS A significantly higher proportion of children in group D (84.7%) achieved an MRS score ≥3 as compared to group K (36.2%) and group S (3.84%). The total propofol dose (mg kg-1) required was significantly less in group D (p<0.01). The patients in group D required more time to awakening, but this difference was not clinically significant. CONCLUSION The present study demonstrated that IN dexmedetomidine is superior to IN ketamine to provide procedural sedation for radiotherapy in children.
Collapse
Affiliation(s)
- Praneeth Suvvari
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sachidanand Jee Bharati
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anaesthesia & Palliative Medicine, Dr BRA-Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - M.A. Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
6
|
Cook-Sather SD, Castella G, Zhang B, Mensinger JL, Galvez J, Wetmore RF. Principal Factors Associated With Ketorolac-Refractory Pain Behavior After Pediatric Myringotomy and Pressure Equalization Tube Placement: A Retrospective Cohort Study. Anesth Analg 2020; 130:730-739. [PMID: 31082971 DOI: 10.1213/ane.0000000000004226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prophylactic analgesic administration reduces pain behavior after pediatric bilateral myringotomy and pressure equalization tube placement (BMT). We hypothesized that postoperative pain in children treated with intraoperative ketorolac would, among several exposures of interest, be strongly associated with ear condition. METHODS We conducted a retrospective cohort study of healthy children (9 months to 7 years) who underwent BMT at the Children's Hospital of Philadelphia or its ambulatory surgery centers from 2013 to 2016. Anesthetic care included preoperative oral midazolam, sevoflurane/nitrous oxide (N2O)/air/oxygen (O2) by mask, and intramuscular ketorolac. Demographic and procedural information included left and right tympanic membrane (normal, retracted, or bulging) and middle ear (normal/no, serous, mucoid, or purulent effusion) conditions. Because tympanic membrane and middle ear conditions were highly concordant and mean maximum Face, Legs, Activity, Cry and Consolability (FLACC) scores (0-10) were not different across the array of abnormal findings, we categorized each ear as normal or abnormal based on middle ear effusion alone. We then defined the ear condition of each child (primary exposure) using bilateral findings: normal/normal, normal/abnormal, and abnormal/abnormal. Secondary exposures included age, BMT history, procedure duration, facility location, and attending surgeon/anesthesiologist pair. The primary outcome was maximum postanesthesia care unit FLACC score: 4-10 (moderate-to-severe pain) versus 0-3 (no-to-low pain). Rescue oxycodone, acetaminophen administration, and emergence agitation were secondary outcomes. Statistical analysis incorporated generalized linear mixed models with random intercepts accounting for the clustering effect of provider pairs. Adjusting for multiple comparisons, significance level was set at P = .004. RESULTS Excluding recurrent cases, 1922 unique evaluable subjects remained. The probability of moderate-to-severe pain behavior (FLACC, 4-10) was 52.4% (95% confidence interval [CI], 50.2-54.6) overall. In a confounder-adjusted model, ear condition was significantly associated with moderate-to-severe pain: compared to bilateral abnormal (effusions), odds ratio (OR) (95% CI) for bilateral normal was 2.2 (1.6-2.9), P < .0001. Younger age (OR, 1.1 [1.1-1.2] per year; P = .001) and longer procedure duration (OR, 1.1 [1.0-1.2] per minute; P = .0008) were likewise related to higher pain. With surgeon added to the model, variance explained by provider pairs decreased from 9.60% to 1.05%. Two secondary outcome associations also emerged: comparing bilateral normal to abnormal ears, ORs were 1.7 (1.3-2.2), P = .0001, for rescue oxycodone and 2.0 (1.2-3.3), P = .008, for emergence agitation. CONCLUSIONS Pain behavior after BMT varies by surgeon and is strongly associated with ear condition. Ketorolac as a single prophylactic analgesic appears less effective in younger children with normal middle ear findings.
Collapse
Affiliation(s)
- Scott D Cook-Sather
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gabrielle Castella
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bingqing Zhang
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Janell L Mensinger
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Jorge Galvez
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ralph F Wetmore
- Department of Otorhinolaryngology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Abstract
Background: The recent addition of intranasal medication options for procedural sedation and analgesia has decreased the need for additional painful procedures such as intravenous lines for medication administration. Intranasal fentanyl (INF) has been used in the prehospital setting, as well as in the emergency department for several years, and is increasingly utilized in other locations such as the neonatal intensive care unit (NICU). A paucity of data exists in these smallest children, so we sought to explore trends in INF use in our NICU. Objective: The objective of the study was to describe INF use in the NICU from December 2014 to December 2017. Design/Methods: A retrospective cohort study was conducted of patients receiving INF in the NICU of a large free-standing quaternary inner-city children's hospital from December 2014 to 2017. Demographic data were abstracted from the medical record including gestational age on administration, post-menstrual age, day of life on administration, sex, medication initial and total dose, reported indication, and documented adverse events. This study was approved by our local institutional review board. Results: A total of 54 patients received a total of 67 INF administrations: 32 women (59%), median day of life on administration = 57.1 (interquartile range [IQR] = 33.7-110.4), median weeks gestation = 26.0 (IQR = 24.1-36.1), post-menstrual age = 38.1 weeks (IQR = 33.1-45.4). Initial doses of medications were 1.49 µg/kg/dose INF (range = 0.5-2 µg/kg). Conclusions: Intranasal adjuncts are increasingly used in the NICU. Starting dose of INF is 1.5 µg/kg/dose, and typically, one dose is given.
Collapse
|
8
|
Abstract
General anesthesia has been unequivocally linked to abnormal development of the central nervous system, leading to neurocognitive impairments in laboratory models. In vitro and in vivo studies have consistently shown that exposure to GABA agonists (eg, volatile anesthetics, midazolam, and propofol) or NMDA antagonists (eg, ketamine, isoflurane, and nitrous oxide) produces dose dependent and developmental age dependent effects on various neuronal transmission systems. Exposure to these drugs increases neuronal cell death in juvenile animals including rats, mice, and non-human primates. The possibility of anesthetic induced neurotoxicity occurring in children has led to concerns about the safety of pediatric anesthesia. A spectrum of behavioral changes has been documented after general anesthetic exposure in young children, including emergence delirium, which may be evidence of toxicity. Most clinical studies are retrospective; specifics about medications or monitoring are unavailable and many of the outcomes may not be sensitive to detect small neurocognitive deficits. Some of these retrospective studies have shown an association between anesthesia exposure at a young age and neurocognitive deficits, but others have not. Practitioners and families should be reassured that although general anesthetics have the potential to induce neurotoxicity, very little clinical evidence exists to support this.
Collapse
Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sulpicio G Soriano
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
9
|
Martin CS, Yanez ND, Treggiari MM, Piper L, Cusick J, Lalwani K. Randomized controlled trial of acupuncture to prevent emergence delirium in children undergoing myringotomy tube placement. Minerva Anestesiol 2019; 86:141-149. [PMID: 31808657 DOI: 10.23736/s0375-9393.19.13591-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Myringotomy tube placement is a pediatric procedure frequently performed under inhalational anesthesia without intravenous line placement. Emergence delirium is common following sevoflurane anesthesia, and can lead to patient harm and escalation of nursing care. Our goal was to determine if intraoperative acupuncture, compared to standard of care, reduces emergence delirium in children undergoing myringotomy tube placement. METHODS Single center, randomized, controlled trial at a university hospital, including children ages 1-6 years with ASA physical status 1-3 scheduled for myringotomy tube placement. Participants were stratified based on midazolam premedication and randomized to intraoperative acupuncture (AC, N.=49) or standard anesthesia care (SC, N.=50). Acupuncture needles were placed in bilateral Heart 7 (HT7) and ear Shen Men points after anesthesia induction. A blinded observer in the PACU assessed emergence delirium using the Pediatric Anesthesia Emergence Delirium (PAED) scale. Endpoints were highest PAED score in the recovery room and post-discharge agitation and sleep quality. RESULTS Patient baseline characteristics were similar between treatment groups. With midazolam premedication, the highest PAED score was 11.6 in patients receiving AC and 12.0 for SC. Without midazolam premedication, the highest PAED was 11.8 in patients receiving AC and 10.7 for SC. The overall PAED score difference between AC and SC groups was 0.33 (95% CI -1.5, 2.2, P=0.723). CONCLUSIONS Intraoperative acupuncture at HT7 and ear Shen Men did not reduce PAED scores after myringotomy tube placement. Based on these data, it is therefore unlikely that a larger study of the same design would demonstrate a significant effect of intraoperative acupuncture on emergence delirium after brief sevoflurane anesthesia. However, other acupuncture points or techniques could be considered.
Collapse
Affiliation(s)
- Christine S Martin
- Department of Anesthesia and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA -
| | - N David Yanez
- School of Public Health, Oregon Health and Science University and Portland State University, Portland, OR, USA
| | - Miriam M Treggiari
- Department of Anesthesia and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Lisa Piper
- Department of Anesthesia and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jordan Cusick
- Department of Anesthesia and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kirk Lalwani
- Department of Anesthesia and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| |
Collapse
|
10
|
Choi EK, Park S, Park KB, Kwak KH, Park S. Postoperative emergence agitation and intraoperative sevoflurane sedation under caudal block in children: a randomized comparison of two sevoflurane doses. Anesth Pain Med (Seoul) 2019; 14:434-440. [PMID: 33329774 PMCID: PMC7713797 DOI: 10.17085/apm.2019.14.4.434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/13/2018] [Accepted: 12/18/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Sub-umbilical surgery under caudal block in conjunction with sevoflurane sedation may be safe in terms of maintaining spontaneous breathing and avoiding complications associated with general anesthesia. However, sevoflurane-induced emergence agitation (EA) continues to be a clinically important phenomenon in children. To compare the incidence of EA in children undergoing sub-umbilical surgery under caudal block with two different doses of sevoflurane. METHODS Forty children (aged 1-5 years) scheduled to undergo inguinal hernia repair under caudal block with sevoflurane sedation via a face mask were randomized into either the low-dose (1.0%) end-tidal sevoflurane concentration group (Group LS) or the high-dose (2.5%) end-tidal sevoflurane concentration group (Group HS). We monitored EA episodes at 5 and 30 min in the post-anesthetic care unit (PACU) by using the fourpoint agitation scale and the Pediatric Anesthesia Emergence Delirium (PAED) scale. RESULTS The four-point agitation scale scores and PAED scores were not different between the groups at 5 min. However, the agitation score was higher in Group HS than in Group LS at 30 min after arriving in the PACU. The time required to recover from sedation was longer in Group HS than in Group LS. CONCLUSIONS Face-mask sedation with 1.0% sevoflurane in conjunction with caudal block may be more effective than that with 2.5% sevoflurane in preventing EA.
Collapse
Affiliation(s)
- Eun Kyung Choi
- Department of Anesthesiology and Pain Medicine,, Yeungnam University College of Medicine, Daegu, Korea
| | - Suyong Park
- Department of Anesthesiology and Pain Medicine,, Yeungnam University College of Medicine, Daegu, Korea
| | - Ki-bum Park
- Department of Anesthesiology and Pain Medicine, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Hwa Kwak
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sungsik Park
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
11
|
Pieper L, Wager J, Zernikow B. Intranasal fentanyl for respiratory distress in children and adolescents with life-limiting conditions. BMC Palliat Care 2018; 17:106. [PMID: 30200942 PMCID: PMC6131941 DOI: 10.1186/s12904-018-0361-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/31/2018] [Indexed: 11/10/2022] Open
Abstract
Background Respiratory distress is one of the most common and frightening symptoms of children with life-limiting conditions. Because treatment of the underlying cause is frequently impossible or insufficient, in many children, symptomatic treatment is warranted. The purpose of this study was to describe the circumstances of the use of intranasal fentanyl in an acute attack of respiratory distress (AARD) in children receiving palliative care, as well as to describe outcomes and adverse events after its use. Methods Children and adolescents treated in a pediatric palliative unit or attended by a specialized home care team between 2010 and 2016 were included in this study. A retrospective chart review was conducted of those who were treated with intranasal fentanyl for an AARD. Results During the study period 16 children (0.5–18.6 years) with various life-limiting conditions were treated with intranasal fentanyl for AARD. In total, 70 AARDs were analyzed. In 74% of all AARDs, a single dose of intranasal fentanyl was used. Frequent causes for an AARD were excessive secretions and acute respiratory infection. The median starting dose of intranasal fentanyl was 1.5 μg/kg body weight. Labored breathing (96%), tachypnea (79%) and related suffering (97%) improved after treatment. An adverse event occurred in one child. Conclusions Intranasal fentanyl may be a safe and effective medication for the treatment of acute attacks of respiratory distress in children with life-limiting conditions. However, prospective studies with larger sample sizes and a control group are needed to validate these findings.
Collapse
Affiliation(s)
- Lucas Pieper
- Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health - School of Medicine, Witten, Germany
| | - Julia Wager
- Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health - School of Medicine, Witten, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Dr.-Friedrich-Steiner-Str.5, 45711, Datteln, Germany
| | - Boris Zernikow
- Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health - School of Medicine, Witten, Germany. .,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Dr.-Friedrich-Steiner-Str.5, 45711, Datteln, Germany.
| |
Collapse
|
12
|
Do children undergoing bilateral myringotomy with placement of ventilating tubes benefit from pre-operative analgesia? A double-blinded, randomised, placebo-controlled trial. The Journal of Laryngology & Otology 2018; 132:685-692. [PMID: 29998815 DOI: 10.1017/s0022215118001111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A double-blinded, randomised, placebo-controlled trial was conducted to determine whether routine pre-operative analgesia is beneficial in reducing post-operative ear pain following bilateral myringotomy and tube placement. METHODS Forty-five children (aged 3-15 years) were randomised to receive either pre-operative analgesics (paracetamol and ibuprofen) (n = 21) or placebo (n = 24). All children underwent sevoflurane gas induction with intranasal fentanyl (2 mcg/kg) to reduce the incidence of emergence agitation. Post-operative pain scores were measured using the Wong-Baker Faces Pain Rating Scale. Median pain scores taken 90 minutes post-surgery, and the highest pain score recorded prior to 90 minutes, were analysed. RESULTS There were no statistical differences between the median pain scores at 90 minutes or subsequent need for rescue analgesia. Emergence agitation did not occur in any child. Inadvertent ear trauma, use of an intravenous cannula or airway adjunct did not affect pain scores. CONCLUSION Routine pre-operative analgesia does not reduce pain scores in the early post-operative period. Simple analgesics are effective for rescue analgesia in the minority of cases.
Collapse
|
13
|
Kim N, Park JH, Lee JS, Choi T, Kim MS. Effects of intravenous fentanyl around the end of surgery on emergence agitation in children: Systematic review and meta-analysis. Paediatr Anaesth 2017; 27:885-892. [PMID: 28675609 DOI: 10.1111/pan.13181] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Emergence agitation is a serious postoperative problem in children undergoing general anesthesia. The use of fentanyl around the end of surgery has been proposed to prevent emergence agitation. However, the efficacy and disadvantages of this method remain uncertain because previous results have not been consistent, depending on the variable assessed. METHODS In July 2016, the PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, and KoreaMed were searched for randomized controlled trials that compared fentanyl (1 μg/kg) and placebo administered around the end of surgery to prevent emergence agitation after general anesthesia in children between birth and 14 years of age. The collected outcomes included the incidence or score of emergence agitation, variables regarding anesthesia recovery, and adverse events (eg, postoperative nausea or vomiting). RESULTS A total of 10 randomized controlled trials (718 patients, 357 receiving fentanyl) were included. Fentanyl around the end of surgery significantly decreased emergence agitation incidence (emergence agitation: relative risk 0.43, 95% confidence interval 0.35 to 0.53, I2 =0.0%; severe emergence agitation: relative risk 0.50, 95% confidence interval 0.31 to 0.81, I2 =0.0%). From subgroup analyses, fentanyl at the end of surgery was associated with a prolonged postanesthesia care unit stay and increased postoperative nausea or vomiting incidence (weighted mean difference 6.09, 95% confidence interval 2.77 to 9.41, I2 =58.6%; relative risk 2.61, 95% confidence interval 1.58 to 4.33, I2 =32.4%), whereas fentanyl at 10-20 minutes before the end of surgery did not increase postanesthesia care unit stay or postoperative nausea or vomiting risk (weighted mean difference -1.15, 95% confidence interval -5.15 to 2.85, I2 =89.0%; relative risk 1.32, 95% confidence interval 0.66 to 2.66, I2 =0.0%). CONCLUSIONS The current analyses indicate that fentanyl around the end of surgery reduces the incidence of emergence agitation in children undergoing general anesthesia.
Collapse
Affiliation(s)
- Namo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Ha Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Seok Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Taeyang Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
14
|
Robinson H, Engelhardt T. Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives. Local Reg Anesth 2017; 10:41-49. [PMID: 28458577 PMCID: PMC5403003 DOI: 10.2147/lra.s113591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction. RECENT FINDINGS This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED) and emergence agitation (EA). New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed. SUMMARY Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6-4-0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up.
Collapse
Affiliation(s)
- Hal Robinson
- Department of Anaesthesia, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Thomas Engelhardt
- Department of Anaesthesia, Royal Aberdeen Children's Hospital, Aberdeen, UK
| |
Collapse
|
15
|
Abstract
Emergence delirium (ED) is a complex of perceptual disturbances and psychomotor agitation that occurs most commonly in preschool-aged children in the early postanesthetic period. The incidence of ED varies between 10 and 80% in children and is perceived as a troublesome clinical situation by 42% of pediatric anesthesiologists. Although these events are often short lived, they increase the risk of self-injury and delayed discharge, require additional nursing staff and can increase medical care costs, all of which are causes for concern. The prevalence of ED has increased with the introduction and growing use of sevoflurane and desflurane, two low-solubility inhalational anesthetics. These agents promote early arousal post anesthetic, which contributes to ED. Physiological factors, pharmacological factors, the type of procedure, the anesthetic agent administered, painful stimuli, and various patient factors can all contribute to ED and thus need to be considered. Recent literature debates the cause-effect relationship between ED and pain, suggesting that they often occur concurrently but are sometimes independent findings. The consistent relation between ED and sevoflurane-based anesthesia has guided many studies to investigate its incidence compared with using other anesthetic techniques or various adjuncts. The risk of ED is lowest when propofol is used as a single-agent anesthetic compared with sevoflurane-based anesthetics. Adjunctive agents can be rated in the following order of most effective to least effective interventions: dexmedetomidine, fentanyl, ketamine, clonidine, and propofol bolus at the end of sevoflurane-based anesthesia. This review summarizes the factors that may predict ED and provides an intervention algorithm to guide effective prevention and treatment.
Collapse
Affiliation(s)
- Arthura D Moore
- Department of Pediatric Medicine, Division of Anesthesiology, MS 130, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Doralina L Anghelescu
- Department of Pediatric Medicine, Division of Anesthesiology, MS 130, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA.
| |
Collapse
|
16
|
Stricker PA, Muhly WT, Jantzen EC, Li Y, Jawad AF, Long AS, Polansky M, Cook-Sather SD. Intramuscular Fentanyl and Ketorolac Associated with Superior Pain Control After Pediatric Bilateral Myringotomy and Tube Placement Surgery. Anesth Analg 2017; 124:245-253. [DOI: 10.1213/ane.0000000000001722] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
17
|
Efficacy and Acceptability of Different Auxiliary Drugs in Pediatric Sevoflurane Anesthesia: A Network Meta-analysis of Mixed Treatment Comparisons. Sci Rep 2016; 6:36553. [PMID: 27830713 PMCID: PMC5103214 DOI: 10.1038/srep36553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 10/13/2016] [Indexed: 01/18/2023] Open
Abstract
Emergence agitation preventive medicine should be combined with pediatric anesthesia because of the high frequency of emergence agitation. However, it is challenging to determine the most appropriate medication that can be introduced into pediatric anesthesia for the sake of emergence agitation prevention. We reviewed and retrieved the data from PubMed and Embase. Various medications were assessed based on several endpoints including Emergence agitation outcomes (EA), postoperative nausea and vomiting (PONV), the number of patients who required analgesic (RA), pediatric anesthesia emergence delirium (PAED), the extubation time, the emergency time and the duration of post-anesthesia care unit (PACU) stay. Both traditional and network meta-analysis were carried in this study. A total of 45 articles were complied with the selection criteria and the corresponding articles were reviewed. Fentanyl demonstrated the highest cumulative ranking probability which was followed by those of ketamine and dexmedetomidine with respect to EA and PAED. When PONV and RA were concerned together, clonidine exhibited the highest cumulative ranking probability compared to other medications. Our study suggested that dexmedetomidine perhaps is the most appropriate prophylactic treatment which can be introduced into anesthesia for preventing emergence agitation.
Collapse
|
18
|
Wang X, Deng Q, Liu B, Yu X. Preventing Emergence Agitation Using Ancillary Drugs with Sevoflurane for Pediatric Anesthesia: A Network Meta-Analysis. Mol Neurobiol 2016; 54:7312-7326. [DOI: 10.1007/s12035-016-0229-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 10/16/2016] [Indexed: 01/10/2023]
|
19
|
Bimodal analgesia vs fentanyl in pediatric patients undergoing bilateral myringotomy and tympanostomy tube placement: a propensity matched cohort study. J Clin Anesth 2016; 32:162-8. [DOI: 10.1016/j.jclinane.2016.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/03/2015] [Accepted: 03/05/2016] [Indexed: 11/20/2022]
|
20
|
Network Meta-Analysis on the Efficacy of Dexmedetomidine, Midazolam, Ketamine, Propofol, and Fentanyl for the Prevention of Sevoflurane-Related Emergence Agitation in Children. Am J Ther 2016; 23:e1032-42. [DOI: 10.1097/mjt.0000000000000321] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
21
|
Somaini M, Engelhardt T, Fumagalli R, Ingelmo P. Emergence delirium or pain after anaesthesia—how to distinguish between the two in young children: a retrospective analysis of observational studies. Br J Anaesth 2016; 116:377-83. [DOI: 10.1093/bja/aev552] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
22
|
Tan Y, Shi Y, Ding H, Kong X, Zhou H, Tian J. μ-Opioid agonists for preventing emergence agitation under sevoflurane anesthesia in children: a meta-analysis of randomized controlled trials. Paediatr Anaesth 2016; 26:139-50. [PMID: 26614352 DOI: 10.1111/pan.12815] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Emergence agitation (EA) is an adverse effect after sevoflurane anesthesia in pediatric patients. The effectiveness of prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil in preventing EA is debatable. METHODS A literature search was conducted to identify clinical trials that observed the effect of μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil on preventing EA in pediatric patients under sevoflurane anesthesia. The statistical software RevMan 5.3 was used for meta-analysis. Data from each study were combined using the relative ratio (RR), weighted mean differences, and their associated 95% confidence intervals. I(2) was used to evaluate heterogeneity. Subgroup analysis was conducted to investigate the possible influences of patient age, adenotonsillectomy, premedication, N2 O, propofol, and regional block/local anesthetics on preventing EA with prophylactic administration of μ-opioid agonists. Publication bias was checked using funnel plots and Begg's test. RESULTS This meta-analysis showed the inclusion of 19 randomized controlled trials with 1528 patients (857 patients received μ-opioid agonists therapy and 671 patients had placebo). The pooled data indicated that prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil significantly decreased the incidence of EA [RR = 0.49 (0.38, 0.64), I(2) = 42%, P = 0.04; RR = 0.57 (0.33, 0.99), I(2) = 37%, P = 0.19; RR = 0.18 (0.08, 0.39), I(2) = 0%, P = 0.98; and RR = 0.56 (0.40, 0.78), I(2) = 6%, P = 0.34, respectively]. All subgroup analyses strengthened the proof for lower incidence of EA under sevoflurane anesthesia after fentanyl administration. A possibility of publication bias was detected in the fentanyl group. CONCLUSIONS This meta-analysis suggested that prophylactic μ-opioid agonists fentanyl, remifentanil, sufentanil, and alfentanil could significantly decrease the incidence of EA under sevoflurane anesthesia in children compared to placebo. Considering the limitations of the included studies, more clinical studies are required.
Collapse
Affiliation(s)
- Yuan Tan
- Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Yisa Shi
- Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Hui Ding
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, China
| | - Xiangbin Kong
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, China
| | - Haijiao Zhou
- Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, China
| |
Collapse
|
23
|
Shi F, Xiao Y, Xiong W, Zhou Q, Yang P, Huang X. Effects of Fentanyl on Emergence Agitation in Children under Sevoflurane Anesthesia: Meta-Analysis of Randomized Controlled Trials. PLoS One 2015; 10:e0135244. [PMID: 26275039 PMCID: PMC4537096 DOI: 10.1371/journal.pone.0135244] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/20/2015] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Fenmei Shi
- Department of Anaesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Xiao
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Xiong
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qin Zhou
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Peng Yang
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiongqing Huang
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
24
|
Son JS, Jang E, Oh MW, Lee JH, Han YJ, Ko S. A comparison of postoperative emergence agitation between sevoflurane and thiopental anesthesia induction in pediatric patients. Korean J Anesthesiol 2015; 68:373-8. [PMID: 26257850 PMCID: PMC4524936 DOI: 10.4097/kjae.2015.68.4.373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 01/30/2015] [Accepted: 02/05/2015] [Indexed: 11/30/2022] Open
Abstract
Background This study was performed to compare the incidence of emergence agitation (EA) between inhalation and intravenous anesthesia induction in children after sevoflurane anesthesia. Methods In this prospective and double-blind study, 100 children aged 3 to 7 years were enrolled. Subjects were randomly assigned to the sevoflurane (Group S) or thiopental (Group T) anesthesia induction groups. Anesthesia was induced using 8% sevoflurane and 4-6 mg/kg thiopental in Groups S and T, respectively. Anesthesia was maintained with nitrous oxide and sevoflurane. The children were evaluated at 5 and 20 min after arrival in the postanesthesia care unit (PACU) with a four-point agitation scale and the Pediatric Anesthesia Emergence Delirium scale. The incidence of EA and administration of the rescue agent were recorded. Results The incidence of EA was significantly lower in Group T compared to Group S at 5 min after PACU arrival (3/49 patients, 6% vs. 12/47 patients, 26%, P = 0.019). However, there was no difference between the two groups at 20 min after PACU arrival (23/49 vs. 19/47 patients in Group T vs. Group S, P = 0.425). The overall incidence of EA was 60% (28/47 patients) in Group S and 41% (20/49 patients) in Group T (P = 0.102). The number of children who received propofol as a rescue agent was significantly lower in Group T (Group S: 14/47 vs. Group T: 5/49, P = 0.031). Conclusions Intravenous anesthesia induction with thiopental reduced the incidence of EA in the early PACU period compared to inhalation induction with sevoflurane in 3- to 7-year-old children undergoing sevoflurane anesthesia.
Collapse
Affiliation(s)
- Ji-Seon Son
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Eunjoo Jang
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Min Wook Oh
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Ji-Hye Lee
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Young Jin Han
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Seonghoon Ko
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| |
Collapse
|
25
|
Comparison of Surgical Pleth Index-guided Analgesia with Conventional Analgesia Practices in Children: A Randomized Controlled Trial. Anesthesiology 2015; 122:1280-7. [PMID: 25815454 DOI: 10.1097/aln.0000000000000650] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children. METHODS This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 μg/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements. RESULTS Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 μg/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 μg/kg; P = 0.04). CONCLUSIONS As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.
Collapse
|
26
|
Somaini M, Sahillioğlu E, Marzorati C, Lovisari F, Engelhardt T, Ingelmo PM. Emergence delirium, pain or both? A challenge for clinicians. Paediatr Anaesth 2015; 25:524-9. [PMID: 25580984 DOI: 10.1111/pan.12580] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children commonly display early postoperative negative behavior (e-PONB) after general anesthesia, which includes emergence delirium (ED), discomfort, temperament, and pain. However, it is often difficult for the caregiver to discriminate between various aspects of e-PONB. OBJECTIVE This prospective observational study evaluates the possibility to distinguish between ED and pain in young children using validated pediatric observational scales in the early postoperative phase. METHODS Following institutional approval and written consent, children undergoing elective adenoidectomy and/or tonsillectomy were enrolled. Following standardized anesthesia, two trained observers simultaneously evaluated children's behavior with the Paediatric Anaesthesia Emergence Delirium Scale (PAED) and with the Face, Legs, Activity, Cry, Consolability scale (FLACC) at extubation, and at 5, 10, and 15 min. RESULTS Of 150 children that completed the study, 32 (21%) had ED, 7 (5%) had pain, and 98 (65%) had simultaneously both ED and pain. The association of 'No eye contact', 'No purposeful action' and 'No awareness of surroundings' (ED1) had a sensitivity of 0.96 and a specificity of 0.80 (PPV 0.97, NPV 0.78) to identify ED. 'Inconsolability' and 'Restlessness' (ED2) had a sensitivity of 0.69 and a specificity of 0.88 (PPV 0.83 and NPV 0.78) to identify pain. CONCLUSION It is difficult to differentiate between ED and pain using FLACC and PAED scores. 'No eye contact', 'No purposeful action', and 'No awareness of surroundings' significantly correlated with ED. 'Inconsolability' and 'Restlessness' are not reliable enough to identify pain or ED in the first 15 min after awakening.
Collapse
Affiliation(s)
- Marta Somaini
- Department of Anaesthesia and Intensive Care, Niguarda Ca' Granda Hospital, Milan-Bicocca University, Milan, Italy
| | | | | | | | | | | |
Collapse
|
27
|
Ingelmo PM, Frawley G, Bortone L. We can't tell emergence agitation from pain, yet. Reply to: Stucke and Weisman 'Can we tell emergence agitation from pain?'. Paediatr Anaesth 2015; 25:218-20. [PMID: 25580659 DOI: 10.1111/pan.12597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Pablo M Ingelmo
- Department of Anesthesia, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.
| | | | | |
Collapse
|
28
|
Abstract
Preoperative anxiolysis is important for children scheduled for surgery. The nature of the anxiety depends on several factors, including age, temperament, past hospitalizations, and socioeconomic and ethnic backgrounds. A panoply of interventions effect anxiolysis, including parental presence, distraction, and premedication, although no single strategy is effective for all ages. Emergence delirium (ED) occurs after the use of sevoflurane and desflurane in preschool-aged children in the recovery room. Symptoms usually last approximately 15 minutes and resolve spontaneously. The Pediatric Anesthesia Emergence Delirium scale is used to diagnose ED and evaluate therapeutic interventions for ED such as propofol and opioids.
Collapse
Affiliation(s)
- Richard J Banchs
- Department of Anesthesiology (MC515), University of Illinois Medical Center, Children's Hospital University of Illinois, 1740 West Taylor Street, Suite 3200 West, Chicago, IL 60612-7239, USA
| | - Jerrold Lerman
- Department of Anesthesia, Women and Children's Hospital of Buffalo, SUNY at Buffalo, 219 Bryant Street, Buffalo, NY 14222, USA; Department of Anesthesia, Strong Medical Center, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA.
| |
Collapse
|
29
|
Liang P, Zhou C, Ni J, Luo Z, Liu B. Single-dose sufentanil or fentanyl reduces agitation after sevoflurane anesthesia in children undergoing ophthalmology surgery. Pak J Med Sci 2014; 30:1059-63. [PMID: 25225526 PMCID: PMC4163232 DOI: 10.12669/pjms.305.4483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 06/06/2014] [Accepted: 06/08/2014] [Indexed: 02/05/2023] Open
Abstract
Objectives: The trail investigated the effect of small dose sufentanil or fentanyl administrated before the end of surgery in reducing the incidence of emergence agitation after anesthesia with sevoflurane in preschool children undergoing ophthalmology surgery, and the incidence of emergence agitation of sevoflurane anesthesia. Methods: From September 2011 to January 2012 January, ninety ASA I-II children, aged from 3-7 years, undergoing ophthalmology surgery in West China Hospital, were randomly assigned to three groups to receive intravenous saline, sufentanil 0.1μg/kg or fentanyl 1μg/kg at 20 minutes before the end of the surgery. Children were scored by scoring system for emergence agitation (SSEA), Children’s and Infants’ Postoperative Pain Scale (CHIPPS) score. Results: The incidence of agitation was 30% in sufentanil group, 36.67% in fentanyl group, and 63.33% in control group. The incidence of sever agitation (SSEA score≥3) was 6.67% in sufentanil group, 23.37% in fentanyl group, and 36.67% in control group. The agitation and pain scores in sufentanil group and fentanyl group were better than those in control group (P<0.05). There was no difference among three groups about time to extubation. Conclusions: We conclude that the incidence of emergence agitation after sevoflurane anesthesia in children undergoing ophthalmology surgery is up to 63.33%. The single dose of sufentanil or fentanyl can reduce the emergence agitation in children anesthesized with sevoflurane, with no adverse effects. The effect of sufentanil is better than fentanyl.
Collapse
Affiliation(s)
- Peng Liang
- Peng Liang, MD, Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Cheng Zhou
- Cheng Zhou, PhD, Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Juan Ni
- Juan Ni, MD, Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhen Luo
- Zhen Luo, MD, Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Bin Liu
- Bin Liu, MD, Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| |
Collapse
|
30
|
Costi D, Cyna AM, Ahmed S, Stephens K, Strickland P, Ellwood J, Larsson JN, Chooi C, Burgoyne LL, Middleton P. Effects of sevoflurane versus other general anaesthesia on emergence agitation in children. Cochrane Database Syst Rev 2014; 2014:CD007084. [PMID: 25212274 PMCID: PMC10898224 DOI: 10.1002/14651858.cd007084.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
Collapse
Affiliation(s)
- David Costi
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Allan M Cyna
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Samira Ahmed
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Kate Stephens
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Penny Strickland
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - James Ellwood
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Jessica N Larsson
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Cheryl Chooi
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Laura L Burgoyne
- Women's and Children's HospitalDepartment of Paediatric AnaesthesiaAdelaideAustraliaSA 5006
| | - Philippa Middleton
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | | |
Collapse
|
31
|
Dewhirst E, Fedel G, Raman V, Rice J, Barry N, Jatana KR, Elmaraghy C, Merz M, Tobias JD. Pain management following myringotomy and tube placement: intranasal dexmedetomidine versus intranasal fentanyl. Int J Pediatr Otorhinolaryngol 2014; 78:1090-4. [PMID: 24814231 PMCID: PMC4160729 DOI: 10.1016/j.ijporl.2014.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 04/07/2014] [Accepted: 04/08/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE Despite the brevity of the procedure, bilateral myringotomy and tympanostomy tube placement (BMT) can result in significant postoperative pain and discomfort. As the procedure is frequently performed without intravenous access, non-parenteral routes of administration are frequently used for analgesia. The current study prospectively compares the efficacy of intranasal (IN) dexmedetomidine with IN fentanyl for children undergoing BMT. METHODS This prospective, double-blinded, randomized clinical trial included pediatric patients undergoing BMT. The patients were randomized to receive either IN dexmedetomidine (1 μg/kg) or fentanyl (2 μg/kg) after the induction of general anesthesia with sevoflurane. All patients received rectal acetaminophen (40 mg/kg) and the first 50 patients also received premedication with oral midazolam. Postoperative pain and recovery were assessed using pediatric pain and recovery scales, and any adverse effects were monitored for. RESULTS The study cohort included 100 patients who ranged in age from 1 to 7.7 years and in weight from 8.6 to 37.4 kg. They were divided into 4 groups with 25 patients in each group: (1) midazolam premedication+IN dexmedetomidine; (2) midazolam premedication+IN fentanyl; (3) no premedication+IN dexmedetomidine; and (4) no premedication+IN fentanyl. Pain scores were comparable when comparing groups 2, 3 and 4, but were higher in group 1 (midazolam premedication with IN dexmedetomidine). There was no difference in total time in the post-anesthesia care unit (PACU) or time from arrival in the PACU until hospital discharge between the 4 groups. The heart rate (HR) was significantly lower in group 3 when compared to the other groups at several different times after arrival to the PACU. No clinically significant difference was noted in blood pressure. CONCLUSION Following BMT, when no premedication is administered, there was no clinical advantage when comparing IN dexmedetomidine (1 μg/kg) to IN fentanyl (2 μg/kg). The addition of oral midazolam as a premedication worsened the outcome measures particularly for children receiving IN dexmedetomidine.
Collapse
Affiliation(s)
- Elisabeth Dewhirst
- Department of Anesthesiology & Pain Medicine, Wexner Medical Center at Ohio State University, OH, United States.
| | - Gina Fedel
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Vidya Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Julie Rice
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, United States
| | - N’Diris Barry
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Kris R. Jatana
- Department of Otolaryngology-Head and Neck Surgery, Nationwide Children’s Hospital and the Wexner Medical Center at Ohio State University, Columbus, OH, United States
| | - Charles Elmaraghy
- Department of Otolaryngology-Head and Neck Surgery, Nationwide Children’s Hospital and the Wexner Medical Center at Ohio State University, Columbus, OH, United States
| | - Meredith Merz
- Department of Otolaryngology-Head and Neck Surgery, Nationwide Children’s Hospital and the Wexner Medical Center at Ohio State University, Columbus, OH, United States
| | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, United States,Department of Pediatrics, Nationwide Children’s Hospital and the Wexner Medical Center at Ohio State University, Columbus, OH, United States
| |
Collapse
|
32
|
Zhang C, Hu J, Liu X, Yan J. Effects of intravenous dexmedetomidine on emergence agitation in children under sevoflurane anesthesia: a meta-analysis of randomized controlled trials. PLoS One 2014; 9:e99718. [PMID: 24932765 PMCID: PMC4059696 DOI: 10.1371/journal.pone.0099718] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 05/19/2014] [Indexed: 11/19/2022] Open
Abstract
Objective Emergence agitation (EA) is a common complication in children under sevoflurane anesthesia. The aim of this meta-analysis was to evaluate the effects of intravenous dexmedetomidine on EA in children under sevoflurane anesthesia. Methods A comprehensive literature search was conducted to identify clinical trials that evaluated the effects of intravenous dexmedetomidine and placebo on EA in children under sevoflurane anesthesia. The search collected trials from MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Web of Science. Analysis was conducted using STATA version 12.0. Data from each trial were pooled using relative ratio (RR) for dichotomous data or weighted mean difference (WMD) for continuous data and corresponding 95% confidence interval (95% CI). Heterogeneity assessment, sensitivity analysis, and publication bias were performed. Results Twelve trials, in which 459 patients received dexmedetomidine and 353 patients received placebo, were included in this analysis. We found that intravenous dexmedetomidine decreased the incidences of EA (RR = 0.346, 95% CI 0.263 to 0.453, P<0.001), and postoperative pain (RR = 0.405, 95% CI 0.253 to 0.649, P<0.001). Intravenous dexmedetomidine also prolonged extubation time (WMD = 0.617, 95% CI 0.276 to 958, P<0.001), and emergence time (WMD = 0.997, 95% CI 0.392 to 1.561, P = 0.001). Further evidences are required to evaluate the incidence of postoperative nausea and vomiting (PONV). Sensitivity analysis strengthened evidences for lower incidences of EA, pain, and prolonged extubation time, and emergence time. Funnel plots did not detect any significant publication bias. Conclusion Meta-analysis demonstrated that dexmedetomidine decreased the incidence of EA in children under sevoflurane anesthesia.
Collapse
Affiliation(s)
- Chengliang Zhang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Jiajia Hu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Xinyao Liu
- Department of Cardiology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jianqin Yan
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- * E-mail: .
| |
Collapse
|
33
|
Bortone L, Bertolizio G, Engelhardt T, Frawley G, Somaini M, Ingelmo PM. The effect of fentanyl and clonidine on early postoperative negative behavior in children: a double-blind placebo controlled trial. Paediatr Anaesth 2014; 24:614-9. [PMID: 24666767 DOI: 10.1111/pan.12388] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Early negative postoperative behavior (e-PONB) is common in children and manifests itself as emergence agitation (EA), emergence delirium (ED), and pain. The objective of this prospective double blind, randomized, placebo-controlled trial was to determine whether IV clonidine or IV fentanyl prior to surgery modifies e-PONB in children. METHODS Ninety children scheduled for subumbilical surgery under sevoflurane anesthesia supplemented with regional anesthesia were randomized to either receive IV clonidine 2 mcg·kg(-1) , IV fentanyl 2 mcg·kg(-1) or placebo (IV saline) before surgery. Primary outcome measures were the incidence of EA, ED and pain during the first hour after awakening. Secondary outcome measures were side effects such as nausea and vomiting and delayed discharge from PACU. RESULTS Eighty-seven children (n = 29 per group) completed the study. EA was present in 10 children (six clonidine, none fentanyl, and four placebo, P = 0.04) whereas ED was observed in 20 children (nine clonidine, three fentanyl, and eight placebo P = 0.13). Sixteen children who received placebo had a CHIPPS score of ≥4 compared with nine children in fentanyl group and 18 children receiving clonidine (P = 0.04). Ten children receiving fentanyl vomited during the first postoperative day, compared with six children in placebo group and none in clonidine group (P = 0.003). Discharge from PACU was not affected. CONCLUSIONS IV fentanyl before surgery but not IV clonidine modifies e-PONB in children undergoing lower abdominal surgery under general anesthesia supplemented with regional anesthesia. The use of fentanyl in this population was also associated with reduced pain scores after awakening but with significantly greater incidence of PONV.
Collapse
Affiliation(s)
- Luciano Bortone
- First Service of Anaesthesia and Intensive Care, Azienda Ospedaliera di Parma, Parma, Italy
| | | | | | | | | | | |
Collapse
|
34
|
Kim J, Kim SY, Lee JH, Kang YR, Koo BN. Low-dose dexmedetomidine reduces emergence agitation after desflurane anaesthesia in children undergoing strabismus surgery. Yonsei Med J 2014; 55:508-16. [PMID: 24532525 PMCID: PMC3936635 DOI: 10.3349/ymj.2014.55.2.508] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Emergence agitation (EA) is frequently observed in children undergoing general anaesthesia. This study tested whether the addition of an intra-operative low-dose infusion of dexmedetomidine to fentanyl treatment reduced the incidence of emergence delirium following desflurane anesthesia in children undergoing strabismus surgery. MATERIALS AND METHODS A total of 96 children (1-5 years old) undergoing strabismus surgery were enrolled. Anaesthesia was induced with propofol and maintained with desflurane. After induction, fentanyl (1 μg/kg) was administered to all children. During surgery, patients were infused with 0.2 μg/(kg·h)⁻¹ dexmedetomidine (Group FD, n=47) or normal saline (Group F, n=47). Postoperative objective pain score (OPS), Paediatric Agitation and Emergence Delirium (PAED) score, and EA score were documented every 10 minutes in the post-anaesthesia care unit. RESULTS There were no significant differences between the two groups in demographic characteristics and haemodynamic changes. The mean values of maximum EA, maximum PAED, and maximum OPS score were significantly lower in Group FD than in Group F at 0, 10, and 20 minutes after arrival at the post-anaesthesia care unit (p<0.001). The frequency of fentanyl rescue was lower in Group FD than in Group F (p<0.001). The incidence of severe EA was significantly lower in Group FD than in Group F (12.8% vs. 74.5%, p<0.001). CONCLUSION Intra-operative low-dose infusion of dexmedetomidine in addition to fentanyl reduces EA following desflurane anaesthesia in children undergoing strabismus surgeries.
Collapse
Affiliation(s)
- Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
| | | | | | | | | |
Collapse
|
35
|
Zhang C, Li J, Zhao D, Wang Y. Prophylactic midazolam and clonidine for emergence from agitation in children after emergence from sevoflurane anesthesia: a meta-analysis. Clin Ther 2013; 35:1622-31. [PMID: 24075150 DOI: 10.1016/j.clinthera.2013.08.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/26/2013] [Accepted: 08/21/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergence agitation (EA) after emergence from sevoflurane anesthesia is a common phenomenon in children. The efficacy of prophylactic midazolam or clonidine in preventing EA is controversial. OBJECTIVE We performed a meta-analysis of clinical trials of the 2 drugs to evaluate their ability to prevent EA in pediatric patients after emergence from sevoflurane anesthesia. METHODS A comprehensive literature search was conducted to identify clinical trials that observed the effect of midazolam and clonidine on preventing EA in children after their emergence from sevoflurane anesthesia. All data were examined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% CI. I(2) was used to assess heterogeneity. Subgroup analysis was used to assess the effects of preoperative analgesics, routes of administration, and dose, and funnel plots were used to check publication bias. RESULTS After a comprehensive literature search, we found 12 papers that met the criteria for inclusion in this analysis, with a total of 447 children in the midazolam group and 767 children in the clonidine group. We found that both midazolam and clonidine decreased the incidence of EA (OR = 0.45 [95% CI, 0.29-0.70], P = 0.0004, I(2) = 46%; and OR = 0.24 [95% CI, 0.13-0.43], P < 0.00001, I(2) = 48%, respectively). Subgroup analysis indicated that preoperative analgesia may decrease the effect of midazolam against EA, whereas for clonidine, neither the route of administration (intravenous or caudal) nor the dose affected the results. Funnel plots did not detect publication bias in the midazolam group, but a bias was detected in the clonidine group. CONCLUSIONS This meta-analysis suggests that prophylactic administration of midazolam or clonidine could significantly decrease the incidence of sevoflurane-induced EA in pediatric patients.
Collapse
Affiliation(s)
- Chengmi Zhang
- Department of Anesthesiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | | | | | | |
Collapse
|
36
|
Locatelli BG, Ingelmo PM, Emre S, Meroni V, Minardi C, Frawley G, Benigni A, Di Marco S, Spotti A, Busi I, Sonzogni V. Emergence delirium in children: a comparison of sevoflurane and desflurane anesthesia using the Paediatric Anesthesia Emergence Delirium scale. Paediatr Anaesth 2013; 23:301-8. [PMID: 23043512 DOI: 10.1111/pan.12038] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2012] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/AIM This randomized control trial was designed to evaluate the incidence of emergence delirium (ED) in preschool children receiving sevoflurane or desflurane anesthesia combined with an effective caudal block. BACKGROUND While ED has been described in children receiving sevoflurane or desflurane anesthesia, a direct comparison between the two agents using a validated ED assessment tool has not been reported previously. METHODS/MATERIALS Two hundred and sixty preschool children scheduled for elective sub-umbilical surgery were randomized to receive sevoflurane or desflurane anesthesia combined with a caudal block. ED was defined as a Paediatric Anesthesia Emergence Delirium scale (PAED) ≥ 10 points. A delirium-specific score (ED I) was calculated from the first three items of the PAED score (eye contact, purposeful actions, awareness of the surroundings) and a nonspecific score (ED II) from the last two items on the PAED score (restlessness and inconsolability) to test the hypothesis that some items of the PAED scale may better reflect clinical ED than others. RESULTS Thirty-one (25%) children in each group demonstrated ED after awakening with ED being of shorter duration in the desflurane group than the sevoflurane group. An ED I score of nine points had a sensitivity of 0.93 and a specificity of 0.94 for ED. An ED II score of five points had a sensitivity of 0.34 and specificity of 0.95 for ED. CONCLUSION Sevoflurane and desflurane anesthesia were associated with similar incidences of ED in children undergoing sub-umbilical surgery and receiving effective regional anesthesia. High scores on the first three items of the PAED scale were highly correlated with ED. The items restlessness and inconsolability had lower sensitivity for the diagnosis of ED.
Collapse
Affiliation(s)
- Bruno G Locatelli
- 1st Service of Anesthesia and Intensive Care, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Kim D, Doo AR, Lim H, Son JS, Lee JR, Han YJ, Ko S. Effect of ketorolac on the prevention of emergence agitation in children after sevoflurane anesthesia. Korean J Anesthesiol 2013; 64:240-5. [PMID: 23560190 PMCID: PMC3611074 DOI: 10.4097/kjae.2013.64.3.240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 09/10/2012] [Accepted: 09/20/2012] [Indexed: 11/13/2022] Open
Abstract
Background The purpose of this study was to evaluate the effects of ketorolac on the incidence and severity of emergence agitation in children recovering from sevoflurane anesthesia. Methods Eighty-five children aged 3 to 7 years were randomly assigned to the control group or the ketorolac group (1 mg/kg ketorolac). The children were evaluated by the Pediatric Anesthesia Emergence Delirium Scale and a four-point agitation scale. Results The median agitation scores did not differ significantly between the two groups. The overall incidence of emergence agitation was similar in the two groups (41% in the control group vs. 32% in the ketorolac group, P = 0.526). The number of children who received rescue drugs for treatment of emergence agitation was not significantly different between the two groups. Conclusions The administration of 1 mg/kg of ketorolac is not effective in decreasing the incidence and severity of emergence agitation in children aged 3 to 7 years after sevoflurane anesthesia.
Collapse
Affiliation(s)
- Deokkyu Kim
- Department of Anesthesiology and Pain Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | | | | | | | | | | | | |
Collapse
|
38
|
Clavijo CF, Lynn RR, Christians U, Galinkin JL. Intranasal Fentanyl for Breakthrough Pain Control. ACTA ACUST UNITED AC 2012. [DOI: 10.4137/cmt.s7298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Breakthrough pain (BTP) is experienced by approximately 65% of children and adults with chronic pain. Undiagnosed or untreated BTP produces negative emotional, physical, and economic consequences. BTP episodes have a rapid onset and short duration. Short acting oral opioids are the cornerstone of BTP management. Oral medications available to treat BTP episodes like immediate-release morphine or oxycodone have a delayed onset of action so that there is a mismatch between the episode of BTP and the effect of the oral opioids. Novel fentanyl delivery systems for BTP offer pharmacokinetic properties that match the time profile of BTP. Among the transmucosal routes, intranasal fentanyl has gained popularity due to its high bioavailability, rapid onset of action, high potency, short duration, and ease of administration. Its efficacy and safety have been demonstrated in adults who are opioid tolerant. Although children with chronic cancer pain also experience BTP, there is paucity of data on the use of intranasal fentanyl for BTP in this age group.
Collapse
Affiliation(s)
- Claudia F. Clavijo
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rachael Rzasa Lynn
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey L. Galinkin
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
- Department of Anesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
39
|
Thorley M, Donaghey S, Edwards P, Copeland L, Kentish M, McLennan K, Lindsley J, Gascoigne-Pees L, Sakzewski L, Boyd RN. Evaluation of the effects of botulinum toxin A injections when used to improve ease of care and comfort in children with cerebral palsy whom are non-ambulant: a double blind randomized controlled trial. BMC Pediatr 2012; 12:120. [PMID: 22873758 PMCID: PMC3472230 DOI: 10.1186/1471-2431-12-120] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 07/28/2012] [Indexed: 12/18/2022] Open
Abstract
Background Children with cerebral palsy (CP) whom are non-ambulant are at risk of reduced quality of life and poor health status. Severe spasticity leads to discomfort and pain. Carer burden for families is significant. This study aims to determine whether intramuscular injections of botulinum toxin A (BoNT-A) combined with a regime of standard therapy has a positive effect on care and comfort for children with CP whom are non-ambulant (GMFCS IV/V), compared with standard therapy alone (cycle I), and whether repeated injections with the same regime of adjunctive therapy results in greater benefits compared with a single injecting episode (cycle II). The regime of therapy will include serial casting, splinting and/or provision of orthoses, as indicated, combined with four sessions of goal directed occupational therapy or physiotherapy. Method/design This study is a double blind randomized controlled trial. Forty participants will be recruited. In cycle I, participants will be randomized to either a treatment group who will receive BoNT-A injections into selected upper and/or lower limb muscles, or a control group who will undergo sham injections. Both groups will receive occupational therapy and /or physiotherapy following injections. Groups will be assessed at baseline then compared at 4 and 16 weeks following injections or sham control. Parents, treating clinicians and assessors will be masked to group allocation. In cycle II, all participants will undergo intramuscular BoNT-A injections to selected upper and/or lower limb muscles, followed by therapy. The primary outcome measure will be change in parent ratings in identified areas of concern for their child’s care and comfort, using the Canadian Occupational Performance Measure (COPM). Secondary measures will include the Care and Comfort Hypertonicity Scale (ease of care), the Cerebral Palsy Quality of Life Questionnaire (CP QoL–Child) (quality of life), the Caregiver Priorities and Child Health Index of Life with Disabilities Questionnaire (CPCHILD©) (health status) and the Paediatric Pain Profile (PPP) (pain). Adverse events will be carefully monitored by a clinician masked to group allocation. Discussion This paper outlines the theoretical basis, study hypotheses and outcome measures for a trial of BoNT-A injections and therapy for children with non-ambulant CP. Trial registration Australia New Zealand Clinical Trials Registry:N12609000360213
Collapse
Affiliation(s)
- Megan Thorley
- Queensland Cerebral Palsy Health Service, Royal Children Hospital, Brisbane, Australia.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Hippard HK, Govindan K, Friedman EM, Sulek M, Giannoni C, Larrier D, Minard CG, Watcha MF. Postoperative Analgesic and Behavioral Effects of Intranasal Fentanyl, Intravenous Morphine, and Intramuscular Morphine in Pediatric Patients Undergoing Bilateral Myringotomy and Placement of Ventilating Tubes. Anesth Analg 2012; 115:356-63. [DOI: 10.1213/ane.0b013e31825afef3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
41
|
Smith J, Rollin AM. The placement of an intravenous cannula is always necessary during general anesthesia in children: a pro-con debate. The case against. Paediatr Anaesth 2012; 22:455-8. [PMID: 22486905 DOI: 10.1111/j.1460-9592.2012.03834.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jonathan Smith
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | | |
Collapse
|
42
|
Pestieau SR, Quezado ZMN, Johnson YJ, Anderson JL, Cheng YI, McCarter RJ, Pena MT, Finkel JC. The effect of dexmedetomidine during myringotomy and pressure-equalizing tube placement in children. Paediatr Anaesth 2011; 21:1128-35. [PMID: 21575102 DOI: 10.1111/j.1460-9592.2011.03615.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bilateral myringotomy (BMT) is a commonly performed otolaryngologic procedure in children. OBJECTIVES To examine the effects of intranasal dexmedetomidine, an α(2)-adrenoceptor agonist, on time-averaged pain scores, pain control, need for rescue analgesia, and agitation scores in children undergoing BMT. METHODS We designed a trial to enroll 160 children randomized to one of four groups: two study groups, dexmedetomidine (1 or 2 μg·kg(-1)), or two control groups representing our institutional standards of practice (intranasal fentanyl-2 μg·kg(-1) or acetaminophen as needed postoperatively). RESULTS After 101 children were enrolled, patient caregivers observed that some enrollees were excessively sedated and required prolonged postanesthesia care unit (PACU) stay. This observation led to an unplanned interim analysis and early trial termination. After data were collected, severe nonnormality of pain and agitation scores necessitated a switch of the outcome to assess repeated measurements of the proportion of patients with pain, severe pain, and agitation. Demographics, time to emergence, and agitation were similar among all groups. The risk of requiring acetaminophen rescue (P < 0.0001) and proportion of patients having pain (P = 0.016) was significantly higher in one control group (rescue analgesia only) compared with fentanyl or dexmedetomidine groups. Importantly, length of stay in the PACU was significantly longer in dexmedetomidine-2 μg·kg(-1)-treated compared with dexmedetomidine-1 μg·kg(-1)-treated, fentanyl-treated, or the control group, P = 0.0037. CONCLUSIONS In this trial, we were unable to answer the original question as to the role of dexmedetomidine on time-averaged pain and agitation scores after BMT. However, our findings clearly demonstrate that in children undergoing BMT, at higher doses, dexmedetomidine significantly prolongs length of stay in the PACU.
Collapse
Affiliation(s)
- Sophie R Pestieau
- Division of Anesthesiology and Pain Medicine, Children's National Medical Center, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA.
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Rampersad S, Jimenez N, Lynn A. Reply to Aidan Cullen Re: Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery, letter. Paediatr Anaesth 2011; 21:1164-5. [PMID: 21966963 DOI: 10.1111/j.1460-9592.2011.03641.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
44
|
Malarbi S, Stargatt R, Howard K, Davidson A. Characterizing the behavior of children emerging with delirium from general anesthesia. Paediatr Anaesth 2011; 21:942-50. [PMID: 21726352 DOI: 10.1111/j.1460-9592.2011.03646.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Emergence delirium (ED) frequently occurs in young children awakening from general anesthesia (GA). To date, research is limited by scales that are unable to discriminate the condition from other forms of agitation. AIM The primary aim of this study was to determine the core behaviors of ED that discriminate the condition from pain and tantrum in young children and to cluster these behaviors according to the DSM-IV/V core diagnostic criteria and associated behaviors of delirium. METHOD Children aged 18 months to 6 years (n=198) were observed upon awakening from GA following surgical or nonsurgical procedures to determine which behaviors categorize ED. Behaviors were recorded via a structured behavioral observation. Clinical opinion was sought to determine whether the child presented ED, pain, or tantrum. RESULTS A chi-square analysis revealed children with ED were significantly more likely to display activity, nonpurposefulness, eyes averted, stared or closed, no language, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum. A logistic regression showed eyes averted or stared and nonpurposefulness were significant predictors of ED, while no language and activity were not significant predictors of ED. CONCLUSIONS Children with ED are significantly more likely to display nonpurposefulness, eyes averted, stared or closed, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum and are believed to reflect the DSM-IV/V diagnostic criteria for delirium. Associated behaviors of ED identified by this research are irrelevant language, activity, and vocalization.
Collapse
Affiliation(s)
- Stephanie Malarbi
- School of Psychological Science, La Trobe University, La Trobe, Victoria, Australia
| | | | | | | |
Collapse
|
45
|
Köner Ö, Türe H, Mercan A, Menda F, Sözübir S. Effects of hydroxyzine–midazolam premedication on sevoflurane-induced paediatric emergence agitation. Eur J Anaesthesiol 2011; 28:640-5. [DOI: 10.1097/eja.0b013e328344db1a] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
46
|
Prommer E, Thompson L. Intranasal fentanyl for pain control: current status with a focus on patient considerations. Patient Prefer Adherence 2011; 5:157-64. [PMID: 21573046 PMCID: PMC3090376 DOI: 10.2147/ppa.s7665] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Indexed: 01/15/2023] Open
Abstract
Of several newer delivery systems under development and investigation for the administration of opioids, the intranasal route has received a substantial amount of attention. Intranasal administration is a convenient form of delivery that is applicable to several opioids. It has the potential for self-administration, combined with a rapid onset of action, allowing for patient-controlled analgesia. In clinical practice, intranasal administration has been found to be a reliable drug delivery method that is familiar to patients. Intranasal opioids have proven to be useful in both in-hospital and out-of-hospital pain management settings. Fentanyl, a highly lipophilic step 3 opioid, has been evaluated for intranasal administration. The purpose of this review is to examine the role of the nasal route of opioid administration and examine the evidence base for the use of fentanyl intranasally.
Collapse
Affiliation(s)
- Eric Prommer
- Correspondence: Eric Prommer, Director of Palliative Care, Division of Hematology/Oncology, Assistant Professor, Mayo Clinic College of Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Room 4E 107, Scottsdale, AZ 85054, USA, Tel +1 480 342 2000, Fax +1 480 342 2088, Email
| | | |
Collapse
|
47
|
Kim HS, Kim CS, Kim SD, Lee JR. Fascia iliaca compartment block reduces emergence agitation by providing effective analgesic properties in children. J Clin Anesth 2011; 23:119-23. [DOI: 10.1016/j.jclinane.2010.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 07/06/2010] [Accepted: 08/11/2010] [Indexed: 10/18/2022]
|
48
|
McGuire JM, Burkard JF. Risk Factors for Emergence Delirium in U.S. Military Members. J Perianesth Nurs 2010; 25:392-401. [DOI: 10.1016/j.jopan.2010.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 07/14/2010] [Accepted: 07/25/2010] [Indexed: 10/18/2022]
|
49
|
Rampersad S, Jimenez N, Bradford H, Seidel K, Lynn A. Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery. Paediatr Anaesth 2010; 20:1028-35. [PMID: 20964769 PMCID: PMC4005868 DOI: 10.1111/j.1460-9592.2010.03427.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective of this study was to determine whether the incidence of emergence agitation (EA) can be reduced by adding an additional, faster onset, non-IV analgesic, intranasal fentanyl or intramuscular (im) ketorolac to rectal acetaminophen. AIM To compare the incidence of EA after analgesia with two agents vs acetaminophen alone in pediatric patients after bilateral myringotomy procedures (BM&T). BACKGROUND Anesthesia for BM&T is usually performed with volatile anesthetics as a single agent without securing intravenous access. The anesthetic agent most commonly used is sevoflurane; however, EA has been reported in up to 67% of patients. Emergence agitation is distressing for parents, can impair the ability of nursing staff to adequately monitor the child, and can result in a child injuring him/herself if it is severe. METHODS/MATERIALS A standardized anesthetic was used with oral midazolam premedication and sevoflurane for induction, and maintenance of anesthesia. All patients received 40 mg·kg(-1) rectal acetaminophen, group 1 received acetaminophen alone, group 2 received acetaminophen and 1 mcg·kg(-1) of intranasal fentanyl, and group 3 received acetaminophen and 1 mg·kg(-1) of intramuscular ketorolac. Incidence of EA was compared using chi-square test between the acetaminophen group alone vs the two-agent analgesia groups combined. RESULTS There were no differences in demographic and clinical characteristics between the two groups. There were no statistically significant differences between the three groups for the incidence of EA at any time point during recovery from anesthesia nor were there any significant differences in pain scores or side effects. No significant side effects because of the administration of a second analgesic agent were reported. CONCLUSIONS We conclude that two-agent analgesia is not superior to acetaminophen alone for decreasing the incidence of EA after inhalation anesthesia with sevoflurane for BM&T surgery. Our overall incidence of EA was low compared to previous studies, which could potentially have decreased our ability to detect differences between groups.
Collapse
Affiliation(s)
- Sally Rampersad
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA 98105, USA.
| | - Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA
| | - Heidi Bradford
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, WA
| | - Kristy Seidel
- Biostatistical Services, Seattle Children’s Hospital, Seattle, WA, USA
| | - Anne Lynn
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
50
|
Bajwa SA, Costi D, Cyna AM. A comparison of emergence delirium scales following general anesthesia in children. Paediatr Anaesth 2010; 20:704-11. [PMID: 20497353 DOI: 10.1111/j.1460-9592.2010.03328.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Emergence delirium (ED) is of increasing interest since the introduction of short-acting volatiles such as sevoflurane. METHODS We compared the Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales for assessing the presence of ED in 117 of 118 consecutive children <18 years recovering from general anesthesia. The primary measure was the worst score for ED as assessed on each scale and for each patient during their PACU stay. An experienced anesthetist observer also made a subjective assessment of the presence of ED. RESULTS A PAED score of > or =10 detected ED in 37 children (32%), while the Watcha detected 30 (26%) and Cravero 41 (35%). Twenty-five patients (21%) fulfilled criteria for ED in all three scales as did all eight patients assessed by the experienced pediatric anesthetist observer. Median PAED scores (interquartile ranges) for patients assessed as having ED or not respectively were for Watcha, 12 (11,14), 7 (4,8); for Cravero, 11 (9,13), 7 (4,8); and for the experienced anesthetist observer, 14.5 (13.5,16.5), 7 (6,10). CONCLUSIONS All three scales correlated reasonably well with each other but have individual limitations in their potential to assess whether ED is present. In the absence of developing an improved research tool to assess ED, a PAED score >12 appears to provide greater sensitivity and specificity than a PAED score > or =10. However, the Watcha scale is a simpler tool to use in clinical practice and may have a higher overall sensitivity and specificity than the other scales.
Collapse
Affiliation(s)
- Samira A Bajwa
- Department of Paediatric Anaesthesia, Women's and Children's Hospital, Adelaide, SA, Australia
| | | | | |
Collapse
|